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PERMITTEE NAME/ADDRESS dn, l wk Facidn- Name2a adim ifDif mnr) <br />NAME <br />ADDRESS 7f-! NE <br />FACILITY <br />LOCATION <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 />Form Approved. <br />OMB No. 2040.0004 <br />;HI_A N <br />', <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 />EF : F. L- MEASUREMENT <br /> PERMIT u. t tl.,R ? z ?1'..•. i f'T:" I: - Tom'. , <br />r. i ' tl=t,i : _ REQUIREMENT ! l <br /> SAMPLE <br /> ! MEASUREMENT <br /> PERMIT a r a r.. T p-ti! <br /> REQUIREMENT <br /> SAMPLE <br />r ,' c u + MEASUREMENT <br /> PERMIT . a <br />,t - REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT n HE, <br />T RL'v <br />;F?t <br /> REQUIREMENT 3t?i <br /> SAMPLE <br />' . ! i_- 71= - _ r . <br />% ,: :- <br />MEASUREMENT <br /> PERMIT q .; , r _.,r r.ft! <br />='F FL U?-ItiT REQUIREMENT <br />1 SAMPLE <br /> MEASUREMENT <br /> PERMIT L; <br />c - REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT REPORT %f.. <br /> REQUIREMENT T. 1_Y r'i ; <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under my direction or supervision to accordance with a system deeigrxd <br />y/ <br />Sf <br />1 / `(/ <br />1 to assure that qualified personnel properly gather and evaluate the infomwtion ?I <br />lJ <br />B submitted. Based on my inquiry of the person or persons who manage the system. <br /> or those persons directly responsible for gathering the information. the information <br />1 to the best of m <br />knowled <br />e arwl belief <br />true <br />accurate <br />and complete <br />b <br />itted is r G ' 2 <br />C/ 1 l L r <br />? . <br />, <br />y <br />g <br />. <br />. <br />, <br />su <br />m <br />itt <br />l <br />t <br />h <br />fi <br />t <br />lt <br />f <br />b <br />f <br />i <br />f <br />I <br />h SIGNATURE OF PRINCIPAL EXECUTIVE ? . <br /> <br />TED <br />A or su <br />m <br />se <br />ormu <br />,..n. <br />am aware t <br />at t <br />en: are signi <br />can <br />pena <br />ies <br />ing <br />a <br />n <br />k <br />i <br />i <br />ibil <br />f f <br />d <br />l OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />PRIN <br />TYPED 0 ity o <br />:nr an <br />rmpnsomnr ! b r <br />nosvmg v <br />n <br />ar <br />un` <br />including the poss CODE <br />(;UMMtNI J ANU tAI LANAI IVIY Ur ANT VIVIL- t11VN.7 Ir7C/Cr CIrt:C all altaL.11111wrI1J r1Cr C/ <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 00065 This is a-4-part form.