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PERMITTEE NAME/AODRESSpweV/.Fr?YgX?lr/Ler.u.n(/D?Qirw+rl <br />NAME <br />ADDRESS <br />FACILITY i <br />LOCATION i?? <br />VF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SY8TEM NPOES/ <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMaER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />NOTE: Road Inehuctione before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. NCY <br />FREO <br />U SAMPLE <br /> O <br />f <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE , <br /> MEASUREMENT <br /> <br /> PERMIT <br />REOUIREMENT <br /> <br />?1L SAMPLE 00 <br /> MEASUREMENT <br /> <br />,l i ., PERMIT <br />A'!(: <br />3DDA <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT ?p? <br />/V?` <br /> PERMIT <br />REQUIREMENT <br />iidP, r ?ta?;? <br /> <br /> <br />F+ SAMPLE <br />MEASUREMENT <br />- <br />- (J <br /> C <br /> PERMIT <br />-Y `•; X <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />t -"' r . er penalty a aw that thh do ,,m of and ail altarhrnenu W,T TELEPHONE <br />NAME/T1TLE PRIN PAL EXECUTIVE OFFICER prepared order my dirertion or wperN7lon in mcm anee with a eyftean ddgnee DATE <br />1? 1 to awun that "alined personnel properly gather and evaluate the Information <br />'I enbMtted. Dowd m my Inquiry of tM person oe person who manage tM System. <br />or thaw directly refpeedble for gathering the'nrornwtton, the Information i LA? ? \ :'/? / 1? <br />' L' '1. submitted fa, to the belt army Laowled ¦nd beDH. trw. accurate, and ! , . I x ! <br />V U <br />I am -re that thrre arc rigninrani penatnea for rabmltung Wee Inrermati n <br />SIGNATURE OF PRINCWAL EXECUTNE <br />D , <br />Includin <br />th <br />onthlut, or fl r and i <br />t f <br />i <br />? <br />TYPED OR PRINTE g <br />e p <br />mpr <br />vonmen <br />or <br />nowfng Oelatf n OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reforence op arrachments hare) <br />R f'F7Fr I P EVENT !"T C!_A T MED. IF CLAIM r . <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used. -Tits i 8'4-pair fOTITI. PAGE OF