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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME ~l~.~;'~'~~"~~ ~i.~~i..~ "' C®~.C#I~ttQa~1C1. L.E~C
<br />ADDRESS §'+{~i~! k`IC~{~ .~ ~®{V ~ ~ I~~
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<br />FACILITY !'~~'1tiJ i-~CJi~ ~ ~I~I~ kvl~S~?r.
<br />LOCATION C~it~~ ~ ~ ~ ~ ~ ~ „~,~,~
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~~ v~•, .. TO U't~ 'Ltd: .. ~.`
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before completing this forma
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all 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 ~
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<br />v~`~ 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 />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />~ SIGNATURE OF PRINCIPAL EXECUTIVE ( /
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<br />TYPED OR PRINTED I am aware that [here are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ~~~ ~!'j ~} ~ ~,;j~"~~g ~ 4-•~fp~, PAGE 60F
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