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PERMITTEE NAME/ADDRESS'Include Facility Acmell oration if Different i NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />- <br />ANIC WADI- <br />Form Approved. <br />OMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING <br /> <br />1 QUALITY OR CONCENTRATION N0, FREQUENCY <br />OF SAMPLE <br /> <br />>< EX TYPE <br /> ANALYSIS <br /> AVERAGE I MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE i <br /> MEASUREMENT', <br /> PERMIT EPO T P ?:: • ?. <br /> REQUIREMENT' SODA AVG DAILY MX MONti <br /> SAMPLE <br /> MEASUREMENTI <br /> PERMIT z E, R i PJ <br /> REQUIREMENT i?i?H AVz CIA 11_i i X <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I L_Y <br /> SAMPLE <br />- MEASUREMENT <br /> PERMIT - - <br /> REQUIREMENT ;ILY <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT € ,4: * •: .- ...- x r- •_ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penults of law that this document and all attachments were <br />with a <br />d u <br />de <br />- di <br />cti <br />r <br />i <br />i <br />n i <br />d <br />c <br />st <br />m de <br />i <br />m-d TELEPHONE DATE <br /> prepare <br />n <br />r <br />on o <br />superv <br />s <br />o <br />n actor <br />un <br />e <br />sy <br />e <br />s <br />g <br />re <br /> to assure that qualified perwnnel properly gather and evaluate the information <br /> submitted. Pl %rd on my inquin of the prrcrm or persu v %Itu manage the ssaem, <br />- <br /> or thou p-om direr U> n Pmtsihlc for gathering the information. the information "-- <br />' submitted is <br />to the best or m) kn-l dge and belief <br />true <br />accurate <br />and complete. <br /> , <br />, <br />. <br />. <br />I <br />h <br />h <br />i <br />if <br />l <br />i <br />i <br />r <br />l <br />i <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED on, <br />um aware t <br />at t <br />em ore s <br />gn <br />icant pena <br />es for submill <br />ng <br />u <br />se <br />ormat <br />t <br />n <br />including the prssibdity or fine and impriamment for knowing tiulations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />A <br />IiUMMC14 1J MIYU CArLMI`eM I tVIY Vr MIYT VIVLM I IVI`IJ II'TCICfulmC lilt Lllp{:III/IC7IIJ /IC/Cl <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. -'"? 12 1 TfrLg-h.a* -pigl Form.