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PERMITTEE NAME/ADDRESS rlnclade Pacio Namelocation iJDiffaentl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LocaTloN FN co 814L _ FROM TO <br />KARn. RFC LAMATIUIU MANAGE:` <br />Form k?r ved. <br />OMB Nc 40-0004 8 <br />M I NUR <br />( - VEIR JC <br />F - FIND <br />DSCHG TC <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />v <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiry under penalh of low that this document and all attachment, were <br />o <br />idu <br />ce with a y <br />stem desi <br />ned <br />ed u <br />der <br />n di <br />tio <br />. <br />r <br />i <br />a <br />o <br />d TELEPHONE DATE <br /> g <br />prepar <br />n <br />n <br />rec <br />n <br />r <br />up <br />n <br />u <br />n <br />r <br />an <br />y <br />cc <br /> to a,"m that qualified perwnnet properi% Bother and ryahtale the mrorm ttim I <br /> submitted. B." on m) inquire of the Person or per.oro who manage the r)stem, " r <br /> or tho a person% directly recponcibk for gathering the information. the information - <br /> ,uhmiti d is, to the best of m., ktmwkdge and belief, true, necurate. and complete. <br />ti <br />I <br />th <br />h <br />i <br />lfi <br />l <br />i <br />f <br />b <br />i <br />i <br />r <br />l <br />i <br />f $IGNATU E OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED ere are c <br />or.u <br />n <br />orma <br />am aware <br />at t <br />gn <br />"m pera <br />t <br />n <br />m <br />tt <br />ng <br />a <br />se <br />on, <br />Including the ix-iboity or floc and impri-nment for knnaing yhdatiom' OFFI R OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />COMMENTS ANU tAVLANA I IUPI Ur- ANT <br />D Irrererence du dridcnmerns "ere/ <br />1F <br />EPA Form 3320-1 (Rev. 30) Previous editions may be used. OO046 11iis-is it 4-part'form.