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PERMITTEE NAME;ADDRESS rlrrchrJc Fwctlin tiame'L~w:urion i/D~ennr1 <br />NAME - <br />ADDRESS L1c~ i.:::r-. .. ~ i X41_ <br />FACILITY -cn~L.i - ~ ~~c <br />LOCATIONf~q;IL:~Ly :-!7 81b~ifi <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. 20x0-0004 <br />1"1 1. 1`FUR <br />~ SUfiR DW ) <br />F - F I DIAL <br />RF'-2~3 SE3~Z <br />:3L~-N <br />J\ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX ALYSIS <br />A TYPE <br /> N <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br />' <br />~~ <br />PERMIT <br />• <br /> <br />I <br />• :r -,.. <br />'~' ;_ ' ~ ~.'_! REQUIREMENT t.~ <br />- .~ ; . <br />- SAMPLE <br />~( <br />' MEASUREMENT <br />, ERMIT i - ~;~ ~r-~ :, , <br />- P <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />.~~. PERMIT ,. .. ~ ,. .. <br />F =1 . ~. REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />~ x -.. - <br />- <br /> <br />)- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> _ . <br /> <br />PERMIT _ <br /> <br />` ~ - <br />f F ' '.~ ~ ~ REQUIREMENT <br />'_ _:; SAMPLE ^ <br />rt•?R~: ~ MEASUREMENT <br /> • <br />. <br />=' F ~ ' PERMIT <br />REQUIREMENT I"'~: ~•; i <br /> SAMPLE <br />(; j • ~ MEASUREMENT <br />_ PERMIT ~ ,. - ~ :. , . _ ~ <br />- ~ , <br />• REQUIREMENT ~ _ <br />. .. ~ ' , <br />NAME/TITL.E PRINCIPAL EXECUTIVE OFFICER I nniig under penalty u1 law that thtt documem and all atwchmrnts were <br />dtrertiun or supervisuxt rn accordance with a system designed <br />:u-ed under m TELEPHONE DATE <br />y <br />~ / ~ ptep <br />y <br />:o ussurc that qualified personnel properly gather and evaluate the informnnon j.._--T+' <br />"'r U <br />" ~ ' ~ submitted. Based on my i uiry of the iwn or re who mane c the stem, <br />the infurmttion <br />the infixmatinn <br />bl <br />atherin <br />di <br />l <br />( <br />h <br /> <br />~~ 1 ~ ~ i~ ! g <br />, <br />rect <br />y rc~ua+t <br />t <br />ur g <br />or t <br />ose persons <br />suMnrtted rs, to the b~Kt n(my knowledge and belief, true. accurate, and complete <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ _ <br />' ~ ~ ' ~ ~ ~ ~ - r '/ <br />' 7 l <br />~ T <br /> I ant aware hurt there arc significant pcnnltic~ for suhmitting false int:,rrnation. CER OR AUTHORIZED AGENT <br />O <br />F ~~ <br /> <br />ti <br />i <br />u <br />l <br />i <br />f <br />I F <br />I NUMBER <br />CODE YEAR MO DAY <br />TYPED OR PRINTED u <br />uns. <br />sonment <br />+rrow <br />ng c <br />+ <br />ur <br />includine the possibility of fine and impr <br />COMMENTS AND EXPLANAI IUN VF Arvr vIllLAI Ivna (nererence an nnecrvrnCms nvr a! <br />-IF2 RE~IP. EVENT' <br />SAMPLIlVG INSTF: <br />I . A. 1 <br />~- I . ;' <br />tEQUIK <br />PacF ,~. <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. j his is ~ -.-h~lrt 1, ~r:n <br />