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?ERFA;TTEE NAME:ADDRESS <br />NAME <br />ADDRESS I r MINE <br />D. BOA. 459 <br />FACILITY 1:!T9, FIELD <br />LOCATION ,)RF-NCE CD E3 i L26 <br />-OR CE V P A i 7FF7 ?;1t1t • M T NP rar_p <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) ?R <br />" TV) <br />PERMIT NUMBER DISCHARGE NUMBER FINAL <br />MONITORING PERIOD OF MEWL <br />YEAR MO DAY YEAR MO DAY <br />FROM TOi <br />Form Approved. <br />DMB No. 2040-0004 <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQ <br />U <br />ENCY SAMPLE <br /> O <br />F <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ###tt## #i"?#?? 5 ?i##### q, O <br /> REQUIREMENT NA X I M'J!'1 f'iG(•!TH <br /> SAMPLE c <br /> MEASUREMENT <br /> PERMIT = sr?t #ti?t##4 r - ;: ##### F -ART 0.5 ONCE/ - . <br />F?L_LV- REQUIREMENT ; AVG DAIL',' NX MONTH <br /> SAMPLE c <br /> MEASUREMENT <br /> PERMIT srr# #t l£ '£ # k ####?i ###### i ';) _t;'i <br /> REQUIREMENT G E N F <br /> SAMPLE <br />ria MEASUREMENT <br />-)'0` PERMIT REPORT REPL-)RT #.•?: ,:? k,~u:. <..... ,. N?Ei <br /> <br />REQUIREMENT <br />- <br />DAIL?' MX I <br /> MONTH <br /> SAMPLE <br />IiL MEASUREMENT <br />- PERMIT R1POR Y Lc. ?'_ /a. <br /> REQUIREMENT T ~lAX ( . , h10PJT` f <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I AAO?, F <br /> SAMPLE <br /> MEASUREMENT D J <br /> PERMIT <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER cenify under penalty of taw that this document and all atiachm were / TELEPHONE DATE <br /> p <br />,eparord under my direction or supenision in accordance with a system designed <br />. <br />.-- i U JC/ assure that qualified personnel properip gather and evaluate the information <br /> submitt <br />d <br />R <br />d <br />i <br />i <br />f <br />h <br /> e <br />- <br />on my <br />ase <br />nqu <br />ry o <br />t <br />e person or persons who manage the system, i <br /> (ir those per:,, directly responsible for gathering the information. the tnlii oration <br />__!\ , wbmttrd is, to the hest of my kno,eledge and belief, tnu, accurate, and complete <br />- <br />h <br />h <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />Y <br />Q <br /> am .no .me t <br />at t <br />ere ifi ant <br />a <br />si <br />rc <br />gn penalaes for submitting fake infortnatlo n, <br /> <br />TYPED OR PRINTED <br />nchi,Lng the po"ibil <br />ity <br />of <br />tine and impnsomttcnt for knuwmg violations. OFFICER OR AUTHORIZED AGENT AAEA <br />NUMBER <br />YEAR <br />MO <br /> <br />rnAAKAPNTC Akin Cool AKIATIl1?1 AC A\IV 11101 <br />ATIr,A1C _- CODE DAY <br />LIDS LIMIT WAIVED FOR <br />P EVENT SUBJECT TO DURDE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. -)O I b3 % 'has:is a 4-part bDrm.