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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME - : a - I" ?.i_ F ,;,.::+.
<br />ADDRESS
<br />FACILITY r . r * r.? M, •_ ;,rr? ' ..
<br />LOCATION:.^ATEUi, ', ,r
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<br />VP C
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DA4R)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO, DAY YEAR MO„ DAY,
<br />FROM G. + er TO : s
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<br />Form Approved.
<br />M ,( WOO OMB No. 2040-0004
<br />( SUBP Du)
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<br />NOTE: Read Instructions before comDletinq this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were T ELEPHON E 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, the information
<br />/ t t ll
<br />-y
<br />?r' submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />I am aware that there are significant penalties for submitting false information
<br />SIGNATURE
<br />OF P
<br />XECUT
<br />RINCIPAL PAL EE {, j
<br />
<br />TYPED OR PRINTED ,
<br />including the possibility of fine and imprisonment for knowing violations T _
<br />OFFICER OR
<br />AUTHORIZED
<br />AGE AREA
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br /> . CODE
<br />I:UMMLN 1, ANU CAru+1'4ra1 wrn yr mmr vww'tvtva trrtererence an a[;tlGnmen[s nere)
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. CJ C1(?1Q 1 } 1?11Si1?3 ??pait?form. PAGE OF
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