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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME I<:t~~~ i r~E~Ss'~4 ~'l}~I...~ .,.. `;~t~.~4'i~~"a?I"~#s ~..~..~
<br />ADDRESS i~:~#t~ r's~t~ ~:~~~~ ~~y~~
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<br />FACILITY ~'ti2z,=~,•,,f, •S[!'++" ~ ?' ~~~~ I°l.~ M
<br />LOCATION ('•.~~..I.~ y.i~ t.,~ ~ ~ ~~~
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />} g-yDIS,~vCCCH~~ARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YE_R. MO_ DAY. YEAR. MO_ DAY
<br />FROM ..~~-, ~ TO uv u^r ~,y..~
<br />Form Approved.
<br />yy ~pp e~v OMB No. 2040-0004
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<br />NOTE: Read Instructions before completing this form.
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify nnder penalty of law mat this document and au attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br /> to assure that qualified personnel properly gather and evaluate the information
<br /> submitted. Based on my inquiry of the person or persons who manage the system, '
<br /> or those persons directly responsible for gathering the information, the information
<br /> submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> I am aware that there are significant penalties for submitting false information, AREA
<br /> risonment for knowing violations
<br />of fine and im
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<br />COMMENTS AND EXPLANATION, OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. %~Cp3S:a~,,i ~.Tl1Yb'LS-ar4'=~~'t'~di'ril• PAGE pF
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