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PERMI I I EE NAME ADDRESS <br />NAME <br />ADDRESS , <br />FACILITY <br />LOCATION - <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />.. . ; . : t " <br />PERMIT NUMBER DISCHARGE NUMBER - r INAL RBLAN <br />`iH <br />MONITORING PERIOD WA <br />YEAR MO DAY YEAR MO DAY <br />FROM TO - ' <br />NOTE- Read Inetrttr-tinns h.P_fnro rnm iletina 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 <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 t rb i. <br />F f"I . U'.= (J i r REQUIREMENT <br />„ "'.1. ; : 1: `_` SAMPLE <br /> MEASUREMENT <br /> PERMIT n f <br />JF=?1 t 4'-;:.. REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br />VA REQUIREMENT <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br />R' <br />REPO <br /> REQUIREMENT ONIL-Y i•, <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certth under penalty of law that this document and all attachments were <br />re <br />red under m <br />dir <br />ct <br />on <br />r <br />isi <br />d <br />th <br />t <br />d <br />i <br />d TELEPHONE DATE <br />SG U? p <br />pa <br />y <br />e <br />i <br />o <br />superv <br />on in accor <br />ance wi <br />a sys <br />em <br />gne <br />es <br />to assure that qualified persooncl properly gather and e.afuate the tnfomutuon <br /> submitted Based on my inquiry of the person or persons who manage the system, / <br /> <br />-- <br />or thox persons directly respo ible for gathering the information, the infuninmion - <br /> <br />L suhmitt d is, to the beat of my knowicd a and belief. true, accurate, and com letc, <br />g' P <br />n <br />t <br />h <br />th <br />t th <br />i <br />if <br />l <br />f <br />al <br />f <br />i <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />v L -"- <br />Y <br />- <br /> <br />TYPED OR-PRINTED ,u <br />aware <br />pena <br />a <br />ere we s <br />gn <br />ican <br />t <br />es <br />or su <br />ormat <br />mnnng f <br />se in <br />on. <br />i <br />l <br />di <br />th <br />o <br />h <br />of fi <br />d <br />m f <br />lm <br />k <br />l <br />n OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />O <br /> u <br />c <br />u <br />e p <br />sst <br />i <br />ne an <br />impnsomne <br />nowing cto <br />rg <br />r <br />or <br />a <br />ons. CODE M DAY <br />I.VMMCPI IJ AVIV! r-ArL--%F4Ml IW" yr MINT VI JL-Ml IV17A (RUIFUTanf:e dll d1lUG/rr"e095 "ere) <br />tR R1 <br />EPA Form 3320-1 (Rev, 3!99) Previous editions may be used. 1G 1 - This is a 4-patR form.