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Form Approved. <br />PERMITTEE NAME/ADDRESS,/,,lade Facility \amr/1-arion o Ntllerrnt, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) OMB No. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER uLL <br />FACILITY <br />LOCATION <br />nvi3unr?u ?.+ <br />MONITORING PERIOD ;r.l.l I F1.1.13 l u <br />YEAR MO DAY YEAR MO DAY <br />FROM TO L_ I NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 t .: <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 certir7 under pemdh orlaw that this document and all attachments Kerr <br />ared under nit direetiom or su <br />r%icion in ac ordunce with as <br />re <br />%%tem desi <br />ned TELEPHONE DATE <br /> p <br />p <br />p <br />g <br />' <br />In assure that (qualified pervonnel proprrh gather and esalualt the mformatatot <br /> submitted. Based on m) inyuirt of alit Peron or prisons who manage the system. <br /> or those persons direct] recpnnsihic for gathering the information. the information <br /> submitted is. to the hest of m} knowledge and belkr. arm-. accurate. and complete. <br />enaltie, for %obmittin <br />I am aware that there are si <br />nirwam <br />false information <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />TYPED OR PRINTED p <br />g <br />, <br />g <br />including the possihilin of fine and imprisonment for knowing siolation, OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br />COMMENTS AND EXPLANATION OF ANY <br />(Reference all attachments here) <br />EPA Forth 3320-1 (Rev 3199) Previous editions may be used. This is a 4-part form.