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PERMITTEE NAMEIADDRESS ilnclnde FacUin :Yamellacaion if th ferrnr) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS Z. <br />6:) K PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY `A ri is sc MONITORING PERIOD <br />}(}{ Z,;,i LOCATION LA v O e i ?? u YEAR MO DAY YEAR MO DAY <br />FROM TO <br />1 AlUrr- IjAnl'. M TIVF MANAr;FR <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO <br /> <br />. <br />FREDUENCY <br /> <br />OF <br /> <br />SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT L- T ti t.) . <br /> REQUIREMENT ; IJL. i'tA }; <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEfMLE PRINCIPAL EXECUTIVE OFFICER I rrrtif under prnalt) of law that this document and all attachments -err TELEPHONE DATE <br />prelmred under nt) direction or sapenisinn to wrordance with a sAQem dtsiltned <br />`' <br />to assure that qualified Personnel pngxri) gather and rsaltmte the information - <br />submitted. Based on m) inquiry of the Person or persons who manage the system. <br />- <br />- or those persons direcd) responsible for gatheriu4t the information, the information - - <br />• - submitted is, to the hest or m) kno-ledge and belief. true, accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />' <br />I am aware that there are significant penalties for submitting false Information. <br />t rn <br />knowin <br />tions <br />s <br />hilit <br />( <br />t fi <br />d i <br />i <br />o <br />e <br />siol <br />I <br />l <br />di <br />tie <br />R OFFICER OR AUTHORIZED AGENT A <br />REA NUMBER <br />YEAR <br />MO <br />DAY <br />. <br />t <br />) <br />ne an <br />mpr <br />r <br />¢ <br />a <br />nc <br />u <br />ng <br />wos <br />i <br />s <br />nm <br />n <br />TYPED O <br />PRIN D CODE <br />COMMENTS AND EXPLANAIIUN Ur ANT viuLAIiuNzp frfererence an arracnmenrs nerej <br />EPA Form 3320-1 (Rev. 3(99) Previous editions may be used. `' ??!