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PERMI,TIE€NAME/ADDRESS (Include F'ucflrq•:\'urrrdl a rulun tJ()i(Ymru <br />NAME <br />ADDRESS v !r e(_ i'IINE <br />FACILITY <br />LOCATION -t <br />L " <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 M7±!AY? <br />FROM TO <br />Form Approved. <br />OMB No. 20404=4 <br />M I NOF? <br />(SUBR GB <br />F - FINAL <br />NORTFi IS D HAY (30LCH <br />N()TF- Read Instructions bef a comoleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIS SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br />; SAMPLE <br />MEASUREMENT <br />. <br /> PERMIT <br /> <br />REQUIREMENT a. # tt # <br /> <br />_ jt•-;: r. ,. s s <br /> <br />i :,• ,} it ## ti ' FZ E" JK 1 <br /> <br />.= <br />P. <br />REPO <br />; I <br /> <br />i SAMPLE <br />MEASUREMENT 4 G . <br />i Y <br />JFt'r^L <br /> PERMIT <br />REQUIREMENT # R' `'OR <br />'i?.f ?•ltay. =L . <br /> SAMPLE <br />MEASUREMENT _ <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT :e <br /> <br /> PERMIT <br />REQUIREMENT <br />- <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT 4 <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />[REQUIREMENT - <br />NAME,TITLE PRINCIPAL EXECUTIVE OFFICER <br />- 1 «-mtq to icr txmdry of IA% that thk.s document ;md JII attachments were <br />aral under m> dixcnon or superrwon m xcordonce with a sy.tem designed <br />prc TELEPHONE DATE <br />/77 <br />r -- •'? / <br />" e p <br />w assure that qualoied personnel property gather and esahwte the information <br />suhmitted. Based on my inquiry of the person or persons who manage the syetem. <br />the information <br />the mfannatinn <br />ibl <br />th <br />rin <br />f <br />d <br />l <br />_- , <br />-- <br /> <br />7 <br /> , <br />or ga <br />g <br />y respons <br />e <br />e <br />x those perom. <br />nect <br />%ubmittLd is. m the best of my kngwlcdgc and bchef, true. accurate, and cotttplcte. SIGNATURE OF PRINCIPAL EXECUTIVE ' .7 <br />, C/• <br /> <br />TYPED OR PRINTED I am uuuc that there ire signifiwm penalties for mbmnung false information. <br />usludmg the possthdity of fine and imps-nmcnt fot knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE I YEAR MO DAY <br />COMMtNIS ANU tArLANMIIvN yr MINT vtvu+t.. <br />I E?;; Porm 3320-1 (Rev. 3199) Previous editions may be used. <br />-HR PRECIF EL'ENT iS CLAIMED E' <br />PAGE <br />TbIS:LS Zi -P t?'1DRll. OF <br />In