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PERMITTEE NAME/ADDRESS r(ncllr/k Faciltn Nrfms2otiulorr ifDtfftfYllrl <br />NAME <br />,f <br />ADDRESS I T 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 />MINOR <br />(SUBR UW ) <br />F - FINAL <br />pPa TO SOUL <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQOUFENCY SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />?:.., MEASUREMENT <br /> PERMIT <br />F,, ;.j -J r ?f<[ I,-; REQUIREMENT MCJI`+? <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t: <br /> REQUIREMENT . • . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F.y . 1141 t* t . r T CFA ' . <br />= REQUIREMENT + rY1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. # : c <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all atuu:hmcnts Acre TELEPHONE DATE <br /> prepared under my direction or super iclon to accordance Atth a system designed <br />// to assure that yuahfted personnel properly gather and evaluate the informatnnt <br /> submitted. Based on my inyuim of the per on or per,,ons who manage the system. -r•- <br /> or thtwc pem. cis directly responsible for gathering the information. the information <br />_ submitecd is, to the h" of my kno,k lade. and belief. true, accurate, and complete. <br />ifi <br />b <br />b <br />f <br />l <br />i <br />f <br />ti <br />h <br />i <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />R <br />T 1 am aware that t <br />gn <br />es ra a t. <br />:c; Mr su <br />m <br />tting <br />a <br />se <br />n <br />orma <br />on. <br />ere arc s <br />l <br />l <br />bi <br />i <br />f f <br />f <br />k <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED O <br />PRIN <br />ED now <br />ng s to <br />attom, <br />inc <br />uding the possi <br />l <br />ty o <br />ine amt impnu?nmcnt <br />or CODE <br />L;UMMCri 1D AMU r-Ar'LAPIA I IV174 Vr ArIT <br />1f7CICIC!![:C all tll[C[:!!1lIClfli !!C!C/ <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. ,p 133 This is a 4-part form.