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PERMITTEE NAME/ADDRESS (1neY4iaeYtryNae/Lorataw (/D(dlr.ewt/ NATIONAL pOlLl1TANT dSCHMOE ELIMINATION SY9TEM NPOES~ <br />NAME DISCHARGE MONITORING REPORT (D RI <br />ADDRESS - •-- . <br />~Qx Q PERMIT NUMBER dscHMOENt1MeE1l <br />I A MONITORING PERIOD <br />FACILITY gyp. _ r. ~ r .,_ <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ; ~f1 CQ '~' 1 4<. _ FROM TO <br />~ TAM A RFQp t4?NI Mf~~' <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: R~~d Irnt-valtx>. b~tot~ cofnphtinp thh lofm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, EwEOUENCr SAMPLE <br /> <br />EX oc <br />TYPE <br /> ANAlY913 <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT f _ .. - <br />.~ , <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 /> MEASUREti~ENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br /> <br />NAME/T1TlE PRINCIPAL EXECUTIVE OFFICER ' """] " " p`""] ° I.. Ihal thN dotvmenl and au attachmetrls were TELEPHONE DATE <br />prepared uwdn m] direttaon err superekfon In ateerdance w11h • f]slem ddEmA <br />le aaun Thal ~uatlned personnel propcA] La1Mr and e~aluale the In(nrrmllon <br />e4mllttd. heed on in] Inqulr] of fAe ptnM a ptrsoeu wM m.naEe Iht s]sltln, <br />or lhoe proem dlreetl] ropenlble fa ptheAnE the Infotrrutlon, the Infornrllen <br />~ fuErNlled Is. b the Aet of m] knowlMjt and beMef, Irsx, aMlnle, and rompkle. - <br />l am aware Uat lhtre ant s!(dnnnt pendtla for whmltnn <br />hkre Inforrmn <br />•N)NA TYRE OF MIINCNAI EXE CUTtVE <br />n _ <br />TYPED OR PRMITED ~ <br />o <br />, <br />InrlydlrK Ihr posalhluq aJ one and ImpAfonmr"i ror tnowin~ Hol.tloni OFFICER OR AUTNORIZEO AOENT A A NUMElER <br />COOP YEAR MO OAY <br />COMMENTS ANO EXPLANATION OF ANY VIOLATIONS (R~/~r~nc~ aN •Kicnm~nts h~r~/ <br />., r? .-. ,-,_ ?- _ ~ - - ~~.jrnFr, I1- ('r t.?n; ~,nf~,4nV~;} r-:'/ <br />EPA-Form 3320-t (Rev. 3199) Previous editions may be used. TIxJS IS 2 4-Pert COftil. PAGE OF <br />