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.~cti:.i ~~1-i cc h!AN~t.ADDRESS ~. .,, . „ .. ~ . ~. <br />'iAtvSE <br />ADDRESS - <br />FACILITY - <br />.. _. - _. .~ .i t7 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before comDletinq this form. <br />PARAMETER DUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREDUENCY <br />OF SAMPLE <br /> ~ TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />1I' .- MEASUREMENT <br /> PERMIT i . ~_ , <br />"_F'~ REQUIREMENT •tt:?~T` <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I ccni(y undo penalty o[ law that this Joe mtcnt anJ all attachments ware TELEPHONE DATE <br /> prepared under my direction or supervision m accordance with a sgstem designed <br /> to aecurc that yualified pcrsoruxl pn.,prrly gather and renlunte the inhnnnuun <br />~ -_ <br />S~ l~I' /! -~. submitted. Bo+a! un my myuiry u(the person ur prtsnns who rnnnagr the system, ` ~ _ _ i <br /> ur those persons directly responsible for gathering the in(ortnation, the infixrnation --~ ~= - <br />- submitted iti, m the best of my knowledge and helieL true, a-rum[e, and complete. <br />i <br />i <br />i <br />if <br />l <br />i <br />f <br />b <br />i <br />f <br />fi SIGNATURE OF PRINCIPAL EXECUTIVE ' `= ~~( <br /> <br />fl PRINTED mitt <br />I mn .+~+.rc iLat [hare are s <br />gn <br />icant pena <br />t <br />es <br />or.,u <br />ng <br />nlx <br />n <br />+mtut <br />on. <br />i <br />F <br />d i <br />f <br />i <br />l <br />ib <br />• <br />f <br />i <br />k <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED 0 net::d~r.e : <br />,~ poSS <br />stmmem <br />now <br />ng v <br />o <br />ataine <br />thn <br />of <br />ine an <br />mpr <br />ur CODE <br />COMMENTS AND FJ(F'L3irvAl wn ut ArvT vtuuanuna (nererence au arracnmenrs nere~ <br />?4h <br />EPA Form 3320-1 (Rev. 3/99) Previtws edAions may be used. <br />REGIP. EVEf~lT' - SEE t. A. 1. PG. 3. F"OR REQUIREMENT <br />;AMPI_IIVG INSTR.UCTIC7NS - IC. 1. 7. , PG. 14. <br />7'hiS ~:B 4;patE form. <br />