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PERMITTEE NAME/ADDRESS (Include F"i irr NomelLrcarion gUiperenn NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />t:OX PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY is A M I IN E c.; Ili 1' L_ i X YEAR MO DAY YEAR MO DAY <br />LOCATION f EN C 13 81 FROM TO <br />KARD, REC_I AMATION MANAGL <br />Form Approved. <br />OMB No. W40-0004- <br />MIN <br />F - FINAL Roil <br />DSCHG TO TRIB/SAGE CREEK <br />NOTE: Read Instructions before lompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - . , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ...: <br /> REQUIREMENT i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER -tir` raider pond., 4Iee thut this document and all attachment. were <br />di <br />ti <br />i <br />with <br />y <br />t <br />d <br />d <br />d <br />i <br />i <br />d <br />i <br />d TELEPHONE DATE <br /> prepare <br />on or superv <br />on <br />n accor <br />ance <br />a s <br />s <br />em <br />e <br />gne <br />un <br />er nn <br />rec <br />s <br /> to ,,,re that qualined per nnel properl% gather and evaluate the information <br /> %ubmitted. Hayed on m1 Inquiry of the person or per ons who manage the ""tem. <br />/ <br /> or those penom directly re ponsible for gathering the Information. the information v f? <br /> submitted Is, to the best of m) knowledge and belief. true. accurate. and complete. <br />w <br />t th <br />if <br />lti <br />f <br />b <br />itti <br />f <br />l <br />i <br />f <br />ai <br />I <br />h <br />i <br />t <br />SIGNA RE OF PRINCIPAL EXECUTIVE V ?- 1 <br />TYPED OR PRINTED am a <br />are t <br />a <br />ere are s <br />gn <br />can <br />pena <br />or su <br />ng <br />a <br />n <br />orm <br />on. <br />es <br />m <br />se <br />including the possibility of fine and imprisonment for knowing violations OFFIfER OR AUTHORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />(;UMMr-N I, ANU CArL_ANA I IVIY yr omA T <br />W ifn daeserrrrierntaF rrrrrl <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. r This=is-9 4-pwtIfOrm.