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PERMITTEE NAMEIADDRESS (Include F"&y A'ante/loranan if Differrim <br />NAME <br />ADDRESS BOX •.:;r:%3 <br />;_A S I <br />FACILITY I 'E <br />LOCATION -A <br />B I <br />LANCE. Woo"tCi- 11114E MAP4AGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />VIN--R: <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ br , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ;i-a-#;, ?rF 0 F? -1 F- r <br /> REQUIREMENT )UA A` %i 5A 1 LY Fi X <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT h rctr_if,. I <br /> REQUIREMENT l''.' •: I L <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t , <br /> REQUIREMENT + .'I= DAILY I NIX <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _, M1 r . i <br /> REQUIREMENT A AVG <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t I, _ , r <br /> REQUIREMENT I I_ Y <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REFUR <br /> REQUIREMENT <br /> <br />NAMElrITLE PRINCIPAL EXECUTIVE OFFICER I -r-tif> under tenalli of law that this ducument and all attachments were <br />TELEPHONE <br />DATE <br /> prepared under m? direction or supra isiun in wv-dance with a .?stem designrd <br /> to wssure that qualified terumnel Ixnperh gather and esalualr the informuliun <br />- sulinumA. Hax-d on m% inquin of the teruro ur persons who manage the Si strnL <br /> ur thus( persons dirMh responsible for gathering the information, the info rmalian , <br /> h <br />r <br />d <br />l <br />t. comp <br />orhe <br />. true, twcu 1 , an <br />ete. <br />submi1l d I,. In the 1-t of m, knawfedge and <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> tam aware that there are significant penahtirs far submitting false informrtitm, <br />t f <br />wi <br />i <br />d u <br />k <br />li <br />`id OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED OR PRINTED no <br />a <br />ons. <br />including the pussibilin of f <br />ne an <br />nprnnnmen <br />or <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence an arfacnmenrs nerej <br />EPA Form 3320-1 (Rev. 31TA) Previous editions may be used. 00193 ' Tftgc.?sr'a'4-p ttt 46rm.