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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<br />ADDRESS j'«jZ_~ ~'7C)~Y ~ ~S?{Fj j'`) F ~~
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<br />FACILITY i~t~,^3 I-Ilwi~ 3: ~~3~ I"i Y i~~
<br />LOCATION ~~f°LF~s ~~ ~~~,~>^f
<br />n.•r°rnl• st a ns~lr^tr t.svrtr. tti+t~'f~ltd t~r~&,htr9,t'.v.frt°d
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YE R M. - D Y-.
<br />FROM -~~ 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 />PARAMETER
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER t certify under penalty otlaw that this document and all 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 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, [he information ~ w
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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 />. [ am aware that there are significant penalties for submitting false information, AREA
<br />TYPED OR PRINTED 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 vIULA I IuNS (rfererence au arracnmenrs nere~
<br />EPA Form 3320-t (Rev. 3/99) Previous editions may be used. ~~ ~, ¢~ ~' I~~~1%Yi~S^i~°~=ji"~QTIfI. PAGE ~F
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