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PERMITTEE NAMEiADDRESS (llude Pixilin• NomeQ.ccaiion ,t Differeni) <br />NAME <br />ADDRESS ,. <br />FACIUTY <br />LOCATION <br />'Co 816-1- <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 />+-- <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 SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT w Wit , r c ;tJAl_ <br />F, . REQUIREMENT MONTI-1 <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 />NAMElIITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all auachments were <br /> <br />d <br />d <br />d <br />i <br />d <br />i <br />TELEPHONE <br />DATE <br /> prepare <br />un <br />er my <br />irection or supervis <br />on to accordance with a svstkm <br />es <br />gned <br /> <br />/?G7r, 1 to assure that qualified personnel properly gather and evaluate the information <br />submitted Based on my inquire of the person or pcrwm who manage the system ?- <br />` <br /> , <br />or those pennons directly responihfe for gathering the infomwhon. the inlonmuon -? <br /> <br />submitted is, to the best of my knowledge and bchcL true, accurate, and complete <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />; Y ` <br />r? <br />L _ <br /> <br />1 am aware that there are si <br />nificant <br />enalties for submittin <br />false mfonnau,,n ; <br />? ; , <br /> <br />TYPED?i PRINTED g <br />p <br />g <br />. <br />including the po,stbthty of fine and imprisonment for knowin <br />%iotation. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> g CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS <br />EPA Form 3320-I (Rev. 3139) Previous eftons may be used. :?G 1 OG ; This is a -,part fon-n.