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PERMITTEE NAME/A0DRESS(hon6kFar4kry)Vewa?Lararrm((Dj06ww) <br />NAME <br />ADDRESS <br />-KER <br />FACILITY C14iY ,I ?: ; - :_ <br />LOCATION EWE R <br />SAN <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM- JNPDES/ <br />DISCHARGE MONITORING REPORT IDMR) <br />PERMIT NUMBER DISCHAAGE NUMBEN <br />1 <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />OF FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read klatructlorte before compledng this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQU <br />NCY SAMPLE <br /> EX E <br /> ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE -- <br /> MEASUREMENT <br /> PERMIT <br />-UF 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/T1TLE PRINCIP l EXECUTIVE OFFICER Ire rty " r penally ° law that thh document and aN attachm <br />prepared -der my dlreet$cm or mprrvlslon In accordance with a ents were <br />system designed <br />TELEPHONE <br />DATE <br /> t <br />th <br />t <br />NMd <br />0 <br />f <br />h <br />I <br />l <br />t <br />:I / f I r r` g <br />r o ats°re <br />gws <br />proper <br />y ja <br />a <br />Personne <br />w and evaluate t <br />e <br />n <br />ormation <br />l <br />l <br />f <br /> <br />j"- ry o <br />submllted, lewd on my <br />nqu <br />the person or person who manage the tyslem. <br />or thou pe mm directly meponNble for gathering the Information, the InformeUnn <br /> <br />• <br /> submltled b6 to the best of my knowhdge and belef, tree. eceurale, and complete. ' <br />I - ' <br /> nln <br />w <br />ar <br />t th <br />r <br />a <br />t <br />e <br />itn <br />r <br />te <br />l <br />f <br />I <br />ttl <br />f <br />b <br />f BIONATURE OF PRINCIPAL EXECUTIVE <br /> are <br />a <br />ere are <br />g <br />c <br />n <br />p <br />no <br />es <br />or nr <br />m <br />ng <br />a <br />r <br />am a <br />n <br />orrm <br />on, AREA <br />TYPED OR PRINTED InchsdInt the powtbNlty of 11- and ImprW mrnt for knowing vldaUorm OFFICER OR AUTHORIZED AGENT COOE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS fRoforence aM attachments hara/ : q.HR PREC I P EVENT IS CLAIMED. IF CLAIM APPRQVFD BY WQC D.- <br />_ 3UREMENTS - <br />NG 11, <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This is a-4-part form. PAGE OF