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PERMITTEE NAME/ADDRESS (Include Facility Name/Locafion if Different)
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<br />ADDRESS (~~~~"~ ~'~~1i ~.Z~.~~ ~:5~;
<br />FACILITY {;4~ta1 i~`irl;~ ~ ~..~~Pd i°I ~ I`#
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />~; ~ DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />MONITORING PERIOD
<br />YEAR. MO DAY YEA. DAY.
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were
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<br /> 1 am aware that there are significant penalties for submitting false information, AREA
<br />TYPED ~OR PRINTE including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments nereJ
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<br />EPA Form 3320-1 ((Rev. 3/99) Previous editions may be used. ~; `"""''' ` `t "' ''~ PAGE ;QF
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