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PERMITTEE NAME/ADDRESS /IncLtdr forilitr Namdtocatioa iJDifJrrcnti <br />NAME <br />ADDRESS •. <br />~t3 <br />FACILITY <br />LOCATION ~ 3 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />t ~Uf3R MH .i <br />f ~ FINAL. ~~TI <br />r^+.:I 7rl „ni~.lf.,n z~e~/i-i'.~,:. - -RFi~i' <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ;, • h~ y. ~ • , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,, :f. ~ .~ :_ . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , .A <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT •a <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under prwlry of low that tbi. Aacnmrm anti all ultnchmenLs wen <br />e <br />r <br />ti <br />i <br />d <br />d <br />dl <br />• <br />t <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> pr <br />pare <br />un <br />e <br />rec <br />nn nr wp< <br />n accor <br />my <br />n <br />s <br />on <br />ance w <br />t <br />a sy stem <br />esigne <br /> la a+surr that yuali(kd prrwrnttrl properly gather and evaluate the information <br /> •uhmittrd. Rased un my inyulry of the penon or persons wha manage the eraetn. _ <br /> nr those pers.ats dimiir responcibk fur gathering the information, the information • <br /> submitted is. to the bra of my knowkdgr and belief. true. accurate, end aanpkie. <br />I am aware that there arr signifk~ant <br />rnultir• P•r .ubmirtin <br />(wise inhvrttatlort SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED p <br />q <br />. <br />Irtdaeinq the prsibiliN of Roc and imprisonment La Avowing siolatiuas. <br />OFFICER OR AUTHORIZED AGENT <br />CR~E NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3,32x1 iRev. 3/99) Previous ed+tions may be used. This'is a 4-part form. <br />