Laserfiche WebLink
Form Approved. <br />PERMITTEE NAME/ADDRESS ,G+L:.L i .:, ;l::. t;;mrl.:-:: r:,o::! !?: n• n»:1 NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) OMB No. 2040.0004 <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER ?L DELTA <br />`" - <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEARMO DAY <br />_.;1`r;•; i ;r, FROM TO XXX <br />t,, r . NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> ? TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />- PERMIT <br />t -. - r t • r - REQUIREMENT <br /> SAMPLE _ <br />V T MEASUREMENT <br /> <br /> PERMIT <br /> <br /> REQUIREMENT <br /> <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalr. „! law that this drkument and all nuaehments were <br />TELEPHONE <br />DATE <br /> prepared under my d;rrr:+on or supmision in auordance with a system designed <br /> to assure that qualiftc,! x rsonncl properly gather and evaluate the Information <br /> submutcvl Ba+ed on 7- inquiry of the person or persons who manage the system. <br />x <br /> or thou peracuu dim '-. responsbie for gathering the information. the infummtion <br /> -f m <br />knowled <br />e and belief <br />true <br />accurate <br />and com <br />lete <br />ubmiticd is <br />to the t 929-5855 <br />70 008 07 07 <br />JAMES I Q NT , <br />. <br />p <br />. <br />f <br />. <br />x , <br />y <br />g <br />. <br />i <br />f <br />l <br />f <br />b <br />l <br />i <br />f SIGNATURE OF PRIN IPAL EXECUTIVE 1 <br /> *mt aware that there . < igni <br />tcant pena <br />ties <br />or su <br />mitting fa <br />se <br />nfomwt <br />on. <br />f <br />l <br />i <br />l <br />di <br />h <br />i <br />d i <br />i <br />k <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED ne an <br />mpr <br />sonment <br />or <br />nowing v <br />o <br />ations <br />nc <br />u <br />ng t <br />e possibilr, f t CODE <br />COMMENTS AND EXPLANATION OF ANY VwLAI IUNS (rrererence an arracnmenrs nere) <br />t.f.F: E'YIENT TF= C' AIMED EXEM-PT'lDNIE, FROM <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. I C, ThJS 4s J3 :P,art form PAGE OF