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PERMITTEE NAME/ADDRESS (Include F"ffiry Name/Locanon y h !a r <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (D R) <br />Jc ) <br />PERMIT NUMBER DISCHARGE NUMBER NAL ROUT <br />MONITORING PERIOD TESTING FOR 004A <br />YEAR MO DAY YEAR M DAY <br />FROM TO O z .11 -- <br />NOTE: Read Instructions beforedcompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> <br />MEASUREMENT <br />N/,A (1t? r <br /> PERMIT `? EP CiZ ; <br /> REQUIREMENT _ ?NG5AIli <br /> SAMPLE <br /> MEASUREMENT rI J •A t-( <br /> PERMIT 7 <br /> REQUIREMENT ;i <br /> SAMPLE <br /> MEASUREMENT r?1 .1 ! v ` to R <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a- r. t- . l: • x # # „» - <br /> REQUIREMENT <br /> SAMPLE <br />M <br />AS <br />R <br />hl IA <br />4 <br />I j l ;' <br />t 1 1? l <br /> E <br />U <br />EMENT r <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT tJ I L? r{ J Ij I SCK Q G <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> M rJ j? 1?1C Q. Q-VE <br /> EASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rerlif% under penalty of law that thl, document and all attxhments wrre <br />d <br />d <br />di <br />i <br />i <br />i <br />i <br />d TELEPHONE DATE <br /> prepare <br />un <br />er m) <br />rect <br />on or superv <br />s <br />on <br />n accor <br />anee with a syHem designed <br />1 <br />' _ - <br />` <br />` C • ? - - - <br />`K' <br />J I. assure that qualified penrMMl properl% gather and rcaluate the information <br />^ ?( <br />Cl- <br />1 <br />, <br />? <br />l <br />„ wbmilted. Ra, ?4 in m? inquln of the percnn or persau who manage the system, t <br />s??_ <br />r <br />- or those prrsmrs directly respimsible for gathering the information, the information <br /> submitted is. la the hto of m}- knowledge and belief, true, anurale, and cmmpiete- <br />_ <br />--?-- - LAS' I am awan that there are significant penalties for submitting false infurmatiua SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED including the tansibillir of fine awl imprisonment for knowing siolalumn OFFICER OR AUTHORIZED AGENT <br />1 <br /> <br />AREA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />IiVMMC1Y 10 M19N Cerr LMl\M 11V11 Vr MINI 1IIVLM I IVI`t,7 II7t:ICIVIIt:r: all &IIAOLIlllltrlllJ llt:rCJ <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. <br />This he i 4-part form.