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PERMITTEE NAME/ADDRESS Nnrkni FacJIQ• Name.1ocaflon ffDilTerem) <br />NAME <br />ADDRESS' BRAD <br />-, ...:: 1. t <br />FACILITY <br />LOCATION. :ELY <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />lForm Approved. <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />OMB No. 2040-0004 <br />k? <br />NOTE: Read Instructions before completing 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 Z ) <br /> MEASUREMENT <br /> PERMIT t l r. rir#?;s t ^:`s# 777 ..- v:1CE/ V13UAC <br />E F z I REQUIREMENT PION TH <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/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />d <br />d <br />di <br />t <br />i <br />h <br />d <br />i <br />d <br />d TELEPHONE DATE <br /> er my <br />ion or supen <br />slon in accor <br />a swem <br />prepare <br />un <br />rec <br />ance wit <br />es <br />gne <br /> <br />J.,t,l?s <br />Sr ofd ' <br />e to assure that qualified pem7nnel properly gather and e?aluatc the information _ <br />' <br />. submitted Based on m} y inquiry of the <br />person or persons who manage the <br />system, <br /> or those persons directly responsible for gathering the information, the information -- <br />{{?? r .' submitted is, to the best of my knowledge and belief, true, accurate. and complete <br />i am ddR that there err significant penalties for SLbm11t1I1g 73kc i?t 1-!?!l <br />i?wR <br />K SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />.? <br />TYPED OR PRINTED - <br />includi <br />n <br />the <br />e ibilin of fine and im <br />naonmew for kno%my -,;,1 ,- OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> g <br />m <br />p CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. '-)Q 174, -. -Thk Is .:a 4 -part form.