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PERMITTEE NAWADDRESS(1-"FarlbryNr..a/Lecarrw1JDIQwwer) <br />NAME <br />ADDRESS <br />• ?• t]LiX t?+?v <br />FACILITY C <br />t1Jk b iC;ir, it. <br />LOCATION h J i t; <br />i'ALI:..'Ai, <br />(i Al 1 le t n r. n; a r. <br />Form Approved. <br />NATIONAL POLLUTANT 04SCHAROE ELIMINATION SYSTEM NPDES) OMB No 2040-0004 <br />DISCHARGE MONITORING REPORT ID R/ <br />PERMIT NUMBER aSCHMOE NUMBER <br />MONITORING PERIOD ?+ L C b Et <br />YEAR MO DAY YEAR MO DAY <br />FROM TO y_ <br />NOTE: Read Instructions befweZdinpleting this fwm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, UENCY <br />FREO SAMPLE <br /> O <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />• ' <br />' ` E <br /> REQUIREMENT <br /> <br /> <br />/ SAMPLE <br /> MEASUREMENT <br /> PERMIT r, 4' <br /> <br />- <br /> <br />' <br />----- <br /> REQUIREMENT <br /> <br /> SAMPLE <br />' <br /> MEASUREMENT <br /> PERMIT <br /> <br />• • • <br />C <br />:? r. / <br /> <br />r. <br /> REQUIREMENT <br /> AT L 'Y <br /> <br />/ SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />r 1 `? C <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br />- PERMIT tl: tLFUP <br /> REQUIREMENT <br /> <br /> SAMPLE <br />I <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT - <br /> <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I "may " r penalty ° Isw that Ihh document and .II atbchments wers - <br />TELEPHONE <br /> <br />DAT <br /> re .red under my dlnclion or su <br />D P perehton In accordance with , system deigned E <br /> to assure that quallned personnel properly Lather and evaluate IM Information <br /> submllled. Based °n my Inquiry of the person or pereons who manage the system, <br /> or those perv-s directly responsible for gathering the Information, the Information <br /> submitted Is, to the bet of my knowledge and beMef, trve, accvnl, and compkle. <br /> I am aware that them are significant Penalties for submitting rape Informatinn, SIONATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED O-kding the poodblilly of 11- and Imprisonment for knowing 00sitlgn OFFICER OR AUTHORIZED AGENT coDE NUkWR YEAR MO DAY <br />s..vmmuer.a rs.ev ter.. ?.-........... ?. ..... -._?.......... . w. w. ...... ... w..ws....rr.r.w rr wr •./ <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan IOrm. PAGE OF