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PERMI7TEE NAME/ADDRESS Ilnrludr Farili(T ,NalnelLocarioa if UiJJrrenn <br />NAME <br />ADDRESS Nfl a M <br />FAC(uTV <br />LOCATION <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 />OM8 No. 2040-0004 <br />M Z IVOR <br />(SUAR <br />I< ~ ~ <br />M t RISC <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREOUENCV <br />OF SAMPLE <br /> EX TYPE <br /> ANa~YSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,. ;' ~:f _,:: -- <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 ~ ,'i'.' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , , .~ j, ~ ;- : _ ... <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrrtif~ under prnaR~ of law that this dIKUOMnI •nd all alluchlm•ntn wcrr <br />tion a <br />r <br />d <br />d <br />dir <br />eni.io <br />i <br />a <br />ord <br />with <br />s. <br />t <br />d <br />si <br />O <br />d TELEPHONE GATE <br /> pr <br />parc <br />un <br />er m~ <br />ec <br />r wp <br />n <br />n <br />cc <br />ance <br />a <br />s <br />em <br />e <br />R <br />e <br /> 111 Y)Wre Thal yU1111111Y1 pervMnel pfnprrl~' Kalhrr and C~aI1Wtf the InfurmYlian <br /> whmilled. Ruxvl nn me inyuln of the pcrslm or per.lm. who manYltc lhr •)+tem, <br /> or Ihoec pcnom dirrcll. roplmsiMe for yylherinY the Information, Ihr information <br /> whmrurd iti, lu the t11•.! of Im knowladge and 1lelief, tn.c, xrurnte. and annldete. <br />h <br />i <br />if <br />b <br />l <br />i <br />li <br />1 <br />th <br />ltl <br />f <br />itti <br />f <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED crr .Ire . <br />icanl prnu <br />l+ <br />r~ <br />a <br />orma <br />oo, <br />and aware <br />at I <br />¢n <br />or w <br />m <br />se <br />n <br />inclYdin¢ Ihr pn.ibilil~ of lino and impri.omncnl far Amlwin>z lir~lalions. OFFICER OR AUTHORIZED AGENT AREA <br />OD NUMBER <br />YEAR <br />MO <br />DAY <br />I:VMMtIV I, AIVU tAYLAfVA I IVfV yr AIYT <br />(RClC~CRGC iill tl![aGlllRClII, !IClC~ <br />EPA Form 3320-t (Rev. 3199) Previous editions may be used. TIt1S" 1S 8 4-~3f[ f01'f17. <br />