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PERMITTEE NAMEIADDRESS dnelude Facilifj• Name,Ltwation rJDiJeftwlj NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS I!`J. <br />Imo; PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION, YEAR MO DAY YEAR MO DAY <br />FROM TO <br /> <br />NOTE: Read Instructions before COmDletinq 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 /> MEASUREMENT <br /> PERMIT ?;x i, r• :.r Ell <br />- REQUIREMENT <br /> SAMPLE <br />- MEASUREMENT <br /> PERMIT s-' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />it f-47 REQUIREMENT iJ(,, T_i_Y <br />- SAMPLE J <br />_ MEASUREMENT <br /> PERMIT <br />:-L l ? ^.j REQUIREMENT i V G <br />? SAMPLE <br /> MEASUREMENT <br /> PERMIT ::f=.: -: 1(? SIT 2N +r RP, <br /> REQUIREMENT 1 <br /> SAMPLE <br />}= MEASUREMENT <br /> PERMIT `. ' N ?1: , .fit' <br />- - . : ; REQUIREMENT Lf!-!.- <br /> SAMPLE <br />` <br />7 1' - MEASUREMENT <br /> PERMIT , T REPORT I tru: RA <br /> REQUIREMENT r{ V G i;)A I I- Y <br />NAMEJTITILE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this dtn ument and all ;machments were TELEPHONE DATE <br />/ prepared under my direction or supers-tsion in accordance with a system designed <br />h <br />l <br />f <br />l <br />h <br />h <br />d <br />l <br />f <br />n <br />SrU? C- ?? ?S?` gat <br />eva <br />uate t <br />e m <br />or-m <br />to assure that qua <br />i <br />ied personne <br />proper <br />er an <br />ort <br />inquiry of the pcr.on or pemms uho manage the system <br />submitted <br />cd on m <br />Ba <br /> , <br />. <br />s <br />y <br />or those persons directly responsible for gathering the information, the mftwmatitm <br />? <br />? to the best of m <br />knowled <br />e and belief <br />true <br />accurate <br />and complete <br />submm <br />d i 7 <br />i /• <br />- ! ! t _ , <br />, <br />, <br />. <br />a <br />s, <br />y <br />g <br />itti <br />fal <br />i <br />ti <br />th <br />i <br />fi <br />t <br />l <br />i <br />f <br />b <br />f <br />I <br />h SIGNATURE OF PRINCIPAL EXECUTIVE <br />$IGN <br />ATUR ' <br /> g-nt <br />ere ares <br />can <br />pena <br />t <br />es <br />or su <br />m <br />ng <br />se <br />n <br />orma <br />on. <br />am aware t <br />at <br />li <br />f f <br />d i <br />k <br />l <br />h <br />i <br />f <br />i <br />i QF <br />OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPE R PRINTED ty o <br />mprisonment <br />nowing v <br />o <br />at <br />ons. <br />including t <br />e poss <br />bi <br />ine an <br />or CODE <br />GOMMENT5 ANU EXPLANAI IUN U1- ANY VIULAI IUNS (rrererence au arracnmenrs nere/ <br />PP.EC I <br />MPLIN <br />EPA Form 3320-1 (Rev. 3/99) Previous edftions may be used. 00221;- This is-.a 4part form.