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PERMITTEE NAMEIADDRESSp dbfaetWpfX"W j(/p l? NATIONAL POLLUTANT DISCNMGE ELIMINATION SYSTEM (NPOES/ <br />NAME DISCHARGE MONITORING REPORT /DMRJ <br />ADDRESS. <br />LOA 14.:x.. PERMIT NUMBER DISCHARGE NUMBER <br />1 BADE <br />FACILITY SII?r NO#2 ; r. : _'• .: : t!.!E`. MONITORING PERIOD <br />1'- 'FAR PALISADE YEA R DAY YEAR MO D Y <br />LOCATION' <br />NE LSOIN L. KID?-1 I . FROM TO <br />NG D T <br />i <br />NOTF• R..A I...a....N..... Is.Ie r. e.eseevw <br />Form Approved <br />OMB No 2040-0004 <br />fhl. f-- <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />SAMPLE <br /> Ot <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />FFF PERMIT <br />REQUIREMENT <br />t-? I hl Ir!UM - <br />MA X T MUM <br />; <br /> <br /> S AMPLE <br /> MEASUREMENT <br /> <br /> <br />;TF' _ J l u ?; v ??,:-'.. ` PERMIT <br />REQUIREMENT <br /> <br />k MAh <br />? <br />U 'TREATMENT PLAN" SAMPLE <br /> MEASUREMENT <br /> <br />EFFLUENT GROSS VALU? PERMIT ?Ur)P A'. <br />_ _ REQUIREMENT <br />Ti 44in J. <br />V I SUAI- SAMPLE <br /> MEASUREMENT <br />3406 L _ k r-., ... >. <br />t=.F?l_l.1clVr" `kUl ?? VALJ-; PERMIT <br />R <br /> EQUIREMENT <br /> SAMPLE -- - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE - <br /> MEASUREMENT <br /> PER <br />I <br /> M <br />T <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 """y " ft?d,r pe"• fy " 0-w that this document and all attachrnenH were <br />r <br />r <br />d <br />d <br />i <br />TELEPHONE <br /> p <br />epa <br />e <br />un <br />er my d <br />reellon a mite aion In accordance with • system designed DATE <br />I o r• 1 ?? t' to assure that qualified pemariM Properly gather end evaluate the Information 7 <br />I <br /> mbmnted. Sand nn my Inquiry of the penoa a persons who manage the system, - - ram <br />` 6 <br />L <br />, <br /> or thoar peraut a dimity responsf bit (0-r fathering the Inforwulinn, the Information - - <br />bs <br />11 <br />d 6 , -t-? •?` ,_ <br />'" <br /> n <br />su <br />1e <br />, to the bell o(my knowledge and belief, true. simumle, and sompkte. <br /> 1 am ¦wne that there are slgnlflcaal peealdes for <br />bmittin <br />W <br />I <br />f SIGNAT <br />R <br />tN <br /> su <br />g <br />e <br />n <br />ormettion• U <br />E OF Pfl <br />CNAL EXECUTIVE <br />TYPED OR PRINTED Including the possibility of ale and ImpAfpnment fee knowing vfoiat.J a OFFICER OR AUTHORIZED AGENT REA <br />NUMBER <br />C YEAR MO DAY <br />n Cwm A a1 A Tiflal AC a 1JV %/IAI A 71-1- 1 -t O <br />DE <br />-.TDS LIMITATIONS <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may Ile used This 15 a 4-03fi form.