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PERMITTEE NAMEIADDRESS rlnctude Farilirv .vmar1Lnrarion if liifferenr/ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ? ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY - MONITORING PERIOD <br />- n ' -' YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />I an;r t= ?ttt n i- <br />1I NOR <br />(SUOR MIS) <br />? -- F T MAI <br />Form Approved. <br />OMB No. 2040-0004 <br />W4 T R <br />E.?: <br />Z41 NE DRNt? rR I F TU I t_1 I I L_C Un <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE I <br /> MEASUREMENT; <br /> PERMIT <br /> REQUIREMENT .;DA ;'V ' DIG 11- 1.1'( ICJnI Ti- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT z ;- A s r F_r p?,: <br /> REQUIREMENT 1. Dr <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x . R E <br /> REQUIREMENT V I L ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT R. f'{ 1`a " <br /> REQUIREMENT <br />Y <br />DA I L. <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 rertiq under penau> of law that this dlKVment and all attachments Herr TELEPHONE DATE <br /> prepared under mq direetlon or sup-rsisiun in accordance with a sptem desiglted <br /> to usstlre that quuhfied personnel properh gather and es aluate the information -- <br />-- submitted. Rasrd on in% inyuin of the person or per,ons who manage the system. - " <br /> or thost proems directi responsible for gathering the information, the information <br />j submitted is <br />to the best of m <br />kno%led <br />r and belief <br />true <br />an orate <br />and com <br />lete <br /> - <br />% <br />g <br />. <br />. <br />, <br />p <br />. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am uware that there are significant penalties for suhmitting false information. <br />FFI <br />AGENT <br />E <br />TH <br />I AREA <br />TYPED OR PRINTED including the possibility or fine and imprisonment for knowing siolathms. O <br />R OR AU <br />OR <br />ZED <br />C <br />- D NUMBER <br />CO YEAR MO DAY <br />L:UMMr_N I J ANU CAYLAIYA I IVIY Vr AI`I T VIVLA I IVIVJ (AC/Cl CIII:C tllI tllltl(41 /II/CIIID IIC/C/ <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. - t.. 1 22 / CITT gli a 4-part form.