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PERMITTEE NAME;ADDRESS ra,. Gnk Pucdrn „ „I illinv+rl <br />NAME <br />ADDRESS L LLD DADOL' T <br />BOX -1 <br />ENCE <br />FACILITY <br />iFIELD i-1Ii1: <br />LOCATION ENCE , U 6 i <br />:4CF '.l Fi GT rlr=Cf"lkl,. f"_c••hl tv <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <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 />JT <br />:HRG T'O OAK Cr'. <br />riC:Hfifjrtr I? tr <br /> <br />PARAMETER <br />QUANTITY OR LOADING 1-- . nvnu nrauuuutr'na rroro <br />QUALITY OR CONCENTRATION rtt cu <br />NO. mptetitty tin <br />I FREQUENCY <br />OF s ann. <br />SAMPLE <br /> AVERAGE MAXIMUM I UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />MEASUREMENT <br /> ' <br /> <br />iALVE PERMIT <br />REQUIREMENT ##i} <br />a# #stast## <br />^ Fj. rj <br /> <br />i"I I f'd T 191J M ####'t# 9. O <br /> <br />f'tr, X L M V? l <br /> <br />'?'• J .NCE/ <br /> <br />f"I OA' l;. N':TTt <br />i SAMPLE <br />MEASUREMENT <br /> <br /> <br />F C _ ) PERMIT <br />REQUIREMENT ###?i## 3!444+*,l N?s# E#it <br />REPORT <br />30DA .'G <br />0.5 <br />DAIL'r' 1-1;-' <br />MONTH <br /> SAMPLE <br />MEASUREMENT :.. 1 <br /> <br /> PERMIT <br /> <br />REQUIREMENT #st###3F st3f # 3f•?;t#it# ## 1. ?: <br />_ <br />NI ' <br />G =aJT <br /> SAMPLE <br />MEASUREMENT <br /> <br />? <br />, <br /> <br /> <br />VALi PERMIT <br />REQUIREMENT REPORT <br />AVG REPORT <br />DATLY MX C <br />f <br />!!ONTH Ns T-A r\ <br /> <br />_ SAMPLE <br />MEASUREMENT # st <br /> ' <br /> PERMIT <br />REQUIREMENT ^ :t <br /># RL-,PIJRT <br />-45T MAX EJ- ? <br />r•;'-_ !; ####sf # ?...- .:. -t x##### ns <br />•.y > t;; F_ % <br />MONTH I5LJAL <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />I? <br />O <br /> <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITL.E PRINCIPAL EXECUTIV OFFICER <br />I I cenih under pcnaln of law that thus document and all attachments wcrr <br />prepared under my direeuoo or supen isiam in ucordance with a system designed - TELEPHONE DATE <br />4 to as>ure that yu;difrd personnel prnpcrh gathcr:md evaluate the information <br />submitted B •d on my myuiry of die person or pttFms who manage the cyst in. <br />,a thonc persons directly responsible for gathering the information, the information r -71 <br /> sahnuned is. to the best of my knrnr Iedge and bciief. true, accurate. and complete <br />h <br />h <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED O I .o:, -tic t <br />at t <br />ere are significant r<cnalne, for submitting false information. <br />R PRINTED <br />COMMENTS AND EXPI ANATInN OF ANV Vlnl ricludmr [be WsSibihty of tine and im,.nsonment 1,,r knowing violations. <br />ATlnhlc faoro.on^a nu ?f?n{.,. M. {M--% OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />coDE YEAR MO DAY <br />WAIVED FOR 10-YR, PREC Y P EVES <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />rO BURDEN OF PROOF REG <br />,' n 1 i.. , - TMs: is a 4-part form.