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PERMITTEE NAME/ADDRESS pnclude Facility Name/Location ijDijjereny <br />NAME ~aia~..,~3» ~};r~`~~z ~i..f'~~..,~a "' ~~I...i.i~~~~~.~a +...~.°S; <br />ADDRESS I,1~::'rl f"~~.~~ ~ ~~~'~ !v! "1 i~lE <br />IN . ~?. ~03;~ <br />FACILITY i'd~1~! ~;~#+~ 3. ~,;',; aj,( I~ ~~a,3~' <br />LOCATION ~.,~# j(~ ~r~:~r ~~ ~ ~ ~,~~s. <br />c'~ ~ T"I~: R. 4._~~3u~ ~~i3.a`a E"I~dfi lal~~t'~~~~-.I~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />G~1~:3C}C~~t~ s.43 ~:iGk~i r-~ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR. M9.. D/~Y_ YEAR MO _ DAY . <br />FROM "~' - • TO '-' `" r '-".' <br />Form Approved. <br />OMB No. 2040-0004 <br />i'~ ~ I~fOr; <br />67 -- I i~3 a ~I~ ~' 1"t. I~E~6~"~ <br />~1+3~~3`~~I~i~ ~€~P~ic~ ~~D Gt~t...l=1d`~~'~"Y 0;3t~~~~ <br />~••i~•?=r tOIC~ ~~tl.'3~)"t~al'V~k: ~"~~ •~•3~3i•'. <br />NOTE: Read Instructions before completing this form. <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 <br />~~~'vl: ~ I~ r:~#'~~'~~?:t •l s#~f SAMPLE S ~:F,~ . ~~ ~r~'t'c-i~• •+t•~:'#••~•~::••~ •~•~ ~•• •z4 ' <br />°I"#~4~t~ <br />~i~~'~T7"Ib6~d~3Y ~'L.~`,I~ MEASUREMENT <br />;;^^aa <br />r`3L tf~V ~ ~ ~ ;:-; y:3~ L ;.'..~. <br />,.,.. ~i , ~. r- r. I,;-1 <br />:.~. .., d ~. :.. .-. .. ~. r. .. ... .. : Y: :Y'. ~•'z~:i '!'r _.. ....- .t'. ._. r i-::~ <br />~^~+{. t ~ i7~^n ~t lam! t ~A,p ty <br />d:~. i" 1"e.°WL. i'S~ ~l1 L.1 i'~~ tiY i-'iMVd ~REOUIR~~IE~~ _. ...`~.,:':~ _ i~~r. ~. ~. . <br />s ~'lt~°~ }3"~'•a:"~' <br />~~~ P~11''~~ ~~;~tfilv.~ <br />SAMPLE it'i84;'•K.•k•# ~ "Y~~ ~s°::•1:=ii•~ •?r~sr'~s'ity~''•k «~~«:.~:ra: <br />~ 7[ ~Ut'~l_ MEASUREMENT <br />.s PERMIT ~ -- <br />~~~~.°lt~~ 4 ~~Q..i ~~. ~k'''t~.,'T..1P ,RE4UIFtE1VIENT ~'s1:~;.-~ I ~.=iii 3'~~3=~'.O '.£'~#•B:- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REOU I REMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> 'REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />~:' <br />- PERMIT <br />` <br />--_° _ REQUIREMENT -= <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT' <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty otlaw that this document and au attachments were <br />i <br />i <br />d <br />i <br />h <br />d <br />i <br />d .~ TELEPHON E DATE <br /> on or superv <br />sion in accor <br />ance w <br />t <br />a system <br />es <br />gne <br />prepared under my direct ~ <br />C.,...e <br /> to assure that qualified personnel properly gather and evaluate the information <br />+~"'""""' submitted. Based on my inquiry of [he person or persons who manage the system, <br />or those persons directly responsible for gathering the information, the intormalion ~ - y ~ <br />'~'L <br /> <br />~ - <br />l~ <br />to the best of my knowledge and belief <br />true <br />accurate <br />and complete. <br />submitted is <br />~' r_ <br />~ <br />~ O Q <br />G <br />~ ~ <br />Q~ <br />` <br />r'(~t~ ~ S <br />tt , <br />, <br />, <br />, <br />i <br />ifi <br />l <br />i <br />f <br />b <br />i <br />i <br />f <br />l <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE ° ° <br /> <br />TYPED OR PRINTED gn <br />cant pena <br />or su <br />m <br />tt <br />ng <br />a <br />se <br />n <br />ormat <br />on, <br />I am aware that there are s <br />t <br />es <br />including the possibility otfine 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 />~-c,.r-`~'~~ ": r't~ ~.,~'~dEZ`G'w `vi~Ll,.M~~. ~;it'1~'t1)M~} ~. ~~:."I"~'l..~w`~t~d ~` ~C?I.._~'~ ~..~.:"1~'t' I,~r'f_.i~]`.~' ~-I:.k~t ~t?'Yt~?a ~~•~-il/2 ~-~3c~?~2 ~:~"~~:b~fi - <br /> ~~~. I. t~. ~, <br />~~ ~ ~- ~. ~ ~' C~3~ ~; ~4.~f,{ ~ €d ~~i~6~.!'~ ~. C~~? r~~v .t--at~ti~t~l._. ~ i~l~ ~ C~3~a a'!~~?O ~' 1 Cis~!~.i __ ?' . C . :~ ~f; ~'' G. "~ ~3. 3t.~ :.~f~`s' ~:~~ ;!: t..-' ~3'~' <br /> igt~3"tw`~" I~il;b'.#°~"E-{i..,.~t' <br />ra~}C' 7"it eve ~'R}F~ '~}V•'h'! il~'3 1'Y1°r"}i 9~`1~~=}1. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. %,~~,j,:;F~~,'j'~'j~jjl;bc;t~'4=fgitp, PAGE ~OF <br />