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PERMITTEE NAME/ADDRESS ibicla& FacNin• Nawe.locarlon iJDiJjerm/1 <br />NAME <br />ADDRESS i I ivJ_ <br />Y R0- T) I5 <br />'. 645 <br />FACILITY„' i f <br />LOCATION ; . f D 43 x 44.4 t3 <br />. 1 :'f I f.,!." i ?t T It?F tNAI'?IAC`1=F7 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Forrn Approved. <br />OMB No. 2040-0004 <br />/'- <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />F:R..,_ MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <<AL'• <br /> REQUIREMENT <br /> SAMPLE <br />r c':- .'. : is ) MEASUREMENT <br /> PERMIT > s t f? F C;r ? r d1?:A13 <br />_ - T L_U a'a _ ; .d i-. `• REQUIREMENT <br /> SAMPLE <br />7 r- rp,? MEASUREMENT <br />i - PERMIT <br />r. j L (.)-F(,I _ REQUIREMENT 3!?D,a F?VI; <br /> SAMPLE <br />rOl AL REC,OVEHAFL_'._ MEASUREMENT <br />O PERMIT <br />xRrS,rj ': to REQUIREMENT <br /> SAMPLE <br />' 01 AL RI~C VERA& I_ F MEASUREMENT <br /> PERMIT RF-Pn-ftT _-r OR r -: <br />- REQUIREMENT <br />t SAMPLE <br />t i .. :oz-(:QVERABLi7 MEASUREMENT <br /> PERMIT l r, ; .'• <br />J REQUIREMENT <br />NAMEJTITL.E PRINCIPAL EXECUTIVE OFFICER I emit} under penalty of law that this document and all auachments were TELEPHONE DATE <br /> prepur.d under my direction or supertsion in accordance with a system designed <br />- to itssure that qualified personnel properly gather and :?-aluatc the information <br />suhmm d. Bawd on my inquiry of the permin or persons who manage the system. <br /> or those persons diroctly responsible for gathering the information. the information <br /> i <br />d b <br />li <br />i <br />d i <br />d <br />b <br />f <br />l <br />f <br />d <br />l - <br />•- <br />L- my ktioe <br />ge an <br />e <br />e <br />true -:curate. an <br />comp <br />ete. <br />subm <br />tte <br />s, to <br />ie <br />est o <br />et <br />k <br />h <br />f <br />mto <br />h <br />F <br />l <br />i <br />f <br />I SIGNATURE OF PRINCIPAL EXECUTIVE " <br />TYPED,6R PRINTED or c? <br />rrn:m,,n. <br />ere are %ignt <br />cant pena <br />t <br />es <br />tllll!111 {! <br />a <br />e <br />am aware that t <br />including the possibility of fine and imprisonment t,u i rl-% fl i:,d:u:..n• OFFICER OR AUTHORIZED AGENT AR E NUMBER YEAR MO DAY <br />I.VMMtN1.7 AN L) tAYLANAIIVN Vr ANT YIVLMI IVNa (FIVICtulluC all a4lat.IIIIIC/IlJ IICI C? <br />EPA Form 3320-1 (Rev. 3,'99) Previous editions may t:e used. 0003 ? This is a-4-part tofm.