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PERMITTEE NAME/ADDRESS llncfudc Fadfio• NanatlLocarton tjD*rciro NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO FROM DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />Ii - <br />` MEASUREMENT <br /> PERMIT <br />f-c c REQUIREMENT <br /> <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 OFFICER I certify under penalty of law that this doctunent and all attachmcnLs were <br />i <br />d <br />d <br />i <br />i <br />d <br />h <br />d <br />i TELEPHONE DATE <br /> irection or suNr%ts <br />on <br />n accur <br />arke w <br />es:gnr <br />prepan <br />d under my <br />t <br />a system <br />/ i •. <br />: tsyC S <br />)? pf>? (I to assure that qualified personnel properly gather and maluate the information <br />h <br />_ e system, <br />submitted Based on my inquiry of the pcrcon or persons who manage t <br /> or those persons directly resporimble for gathering the information, the information <br />_ d t <br />t <br />t <br />f <br />k <br />l <br />d <br />h <br />f <br />t <br />d <br />l <br />t <br />b <br />d i <br />h <br />b <br /> ge an <br />rue, accura <br />e. an <br />comp <br />s, to t <br />:- <br />o <br />my <br />now <br />e <br />x <br />c <br />. <br />e <br />e. <br />su <br />mitte <br />e <br />h,r -h <br />r , <br />;T <br />c <br />:,1 <br />if <br />c <br />: <br />r <br />u <br />t <br />i <br />h <br />t th <br />t <br />ln SIGNATURE OF PRINCIPAL EXECUTIVE , C <br /> <br />TYPED,OR PRINTED e• <br />n <br />, <br />: <br />_ <br />i <br />- .a <br />7 <br />:. <br />: <br />i <br />am aware t <br />a <br />ere arc sign <br />i <br />an <br />pena <br />including the possibility of firtr rod impnxrm" r; :, r 1:c -. ur_ •. r Lni• "- OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />IiVMMMIY I J ANU G. <br />.nrnarrra rrclcj <br />'!HR PREC <br />?02O <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. Vc F}TIS IS a.4-part IOfill.