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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ijDifferent)
<br />NAME ~~~T~R~ ~U~'#.~~ --' GOL.CI~?i~DrJ, ~,I_~
<br />ADDRESS ~~~~ ~~~~ .~ ~~~~ ~ ~ ~~.
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<br />FACILITY ~i`~1 ; a`C]i~ I ~~l'~ ~"i I T~1E
<br />LOCATION ~f~~iM~y~ O ~ ~ ~ ,~,~~.
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YE MO_ DAY
<br />FROM ~ v~-~ V TO ~-+
<br />Form Approved.
<br />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 />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER [certify under penalty of law that this document and au attachments were TELEPHONE DATE
<br /> prepared under my direction or supervision in accordance with a system designed ~
<br /> to assure that qualified personnel properly gather and evaluate [he 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 '°
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<br />'t"t 'A/1 i`~S -~ submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE Q
<br />t 7~ ~~4 © ~~ ~
<br />~?
<br />
<br />TYPED OR PRINTE I am aware that there are significant penalties for submitting false information,
<br />including the possibility of rme and imprisonment for knowing violations.
<br />OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND tXPLANAIIVN Vf ANY VwLAllvrv~ ~rrererence an arracnmenrs Here/
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. '~(~Cii`~'•'~;'(,~ji!i~bc~g"'ai,a~'4-~~t`~`~31'm. PAGE ~OF
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