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PERMITTEE NAMEIADDRESS (include Facility Namelocation il'Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />_)EN C13 816 FROM TO <br />'. IKfAFPn. RFr.1 AMATTnN MANAGF <br />( SURF! .Jc <br />F - FINA <br />BSOHG TO <br />NOTE: Read Instructions before completing this form. <br />Form Approved. <br />OMB No. 4040-Od04 i <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - j <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT f <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />? <br />I <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEN _ <br />= J <br />y = _ MEASURE <br />T - <br /> PERMIT s.. S: 1 ?V r- L1111 7 <br />- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT Y <br /> SAMPLE F <br /> MEASUREMENT u V <br /> PERMIT - <br /> REQUIREMENT 1 I Loy "I <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I rertif? under Ia,nalty of law that this do e.ment and .11 attaehmenh -err <br />re <br />ared und <br />r n <br />directi <br />r <br />si <br />ion i <br />cco <br />d <br />c <br />with - <br />stem da i <br />ed TELEPHONE DATE <br /> p <br />p <br />e <br />q <br />on o <br />wper <br />s <br />n a <br />an <br />e <br />. <br />ga <br />r <br /> to as-wre that quallrtd personnel Property gather and esaluote the information <br /> whmitl d. Ita-d em m? inquiry or the Perron or persons rho manage the %%%tem. <br />ur th- persons dinvtiy responsible for gathering the information, the Information <br />`-r 4 <br />r <br /> whmitted is, to the hest or m.v knowledge and belief, true, accurate. and complete. <br />I <br />h <br />h <br />i <br />ifi <br />l <br />i <br />f <br />h <br />i <br />i <br />f <br />l <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE t-1 -J <br /> <br />TYPED OR PRINTED am aware t <br />at t <br />ere are s <br />gn <br />cant pena <br />t <br />es <br />or su <br />m <br />n <br />ng <br />a <br />se <br />n <br />ormat <br />at, <br />including the possibility orfinr and impriwnment for knowing slolulions <br />OFFICER OR AUTHORIZED AGENT AREA <br />D NUMBER <br />YEAR <br />MO <br />DAY <br />GOMMtN 15 AND LAPLANA I IUN OF ANY VIULA I IONS (Hererence all afracnments nere) <br />A REASONABLE <br />BE <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. J004 = 'Mrs is" a'3-Part fon-n.