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PERMITTEE NAME/ADDRESS (Include Facflily A'an1.:Qwxalinn,fDr?j'ertznU NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS, rj <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />f - FINAL H <br />ACUTE= WET TESTING FOR 004tA <br />NOTE: Read Instructions before comoletinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT £. 1 i• # t r s <br />_ i J..r'•; ' t-: ?„_ ": 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 />NAMEMTLE PRINCIPAL EXECUTIVE FFICER I certif}' under penalty of law that this document and all attachments were <br />d <br />i <br />d <br />d TELEPHONE DATE <br />/ <br />SGG ('?? u recnon or super, iston to accordance with a system <br />prt:pnrc <br />under my d <br />esigne <br />to assure that qualified personnel properly gather and evalume the informatinl <br />J submitted Based on my inquiry of the person or persons who manage the system, <br /> or thou persons directly responsible for gathering the information. the mf, maticm - - <br />- -? <br /> submitted is <br />true <br />accurate <br />to the best of m> y knowledge and belief <br />and complete. <br /> <br />"? Lam <br />7 1 <br />'? 'r <br />f <br /> <br />C <br /> <br />7 .( <br /> . <br />. <br />, <br />. <br />I am aware that there are si <br />nificant <br />enalocs for submittin <br />false information SIGNATURE OF PRINCIPAL EXECUTIVE . <br />; <br />) _ ? <br /> <br />TYPED OR PRINTED g <br />p <br />g <br />. <br />of fine and imprisonment for knowing violations <br />including the possibilit OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> . <br />y CODE <br />IrVMMC11110 MIYU CA1-L.ANMI IVN Ur M19r VIV6/i 11%J1,1l InclulutILM all tlriawlrrltlllab IICICJ <br />3")RE PF_P!7PT ; i-SO .'TATIETICA!_ F'f)rNT 'FcaTrti,ATr WHICH <br />1 <br />EPA Form 3320-1 (Rev, 3;99) Previous editions may be used. PAGE OF <br />c_)414 7 : Gt?j is a =1?tarc form.