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Form Approved. <br />PERMITTEE NAME/ADDRESS ilaclude Facility' A,unc1.,.iafi,,n it Diflerreii NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER AL RQUT <br />RUNUFF TO T-ROijT CF(EI?V• <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREME <br />T <br />rl ' <br />ll? <br />1/IA <br /> N <br /> PERMIT s r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE t <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 -rob under (malty of taw that this d,wumeni and all atmchmenh were <br />TELEPHONE <br />DATE <br /> prepared under m% directi- or u <br />rv ion in arcortlancr with a s1stem designed <br /> w -'- -- - <br />? I _ -- to a wre that yualiRed pen?-nnel properly gather and etaltale the inrurnmtion ic y <br />1 submitted. KewA on nn inyuu) of the prr.,n or Ix-m, who managr the -,tem. <br /> or Ihnse penons directiv re.twmsible for gathering the information, the infornution <br />_ <br />( <br />• <br />? <br /> <br />`- suhmitted Is, to the txsl of ms knowledge and tirlier, true. accurate. and comp(rle. <br />I am awarr that them are signdirmn <br />umultirs for suhmnting fal.e information <br />SIGNATURE OF PRINCIPAL EXECUTIVE % <br />1 ' , <br />-' <br />C: ' ?.' <br /> t <br />. OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the po,%ibi16 of fine amt imprisonment for knowing siolatium. NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. C' This is a 4-part fOrm.