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PERMITTEE NAMEIADDRESS (Include Pacilirr Name/Locarimt iJlh%jrrent) <br />NAME <br />ADDRESS L <br />FACILITY <br />LOCATION _ <br />1. 4"N 1, j : NE '"ANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. ZMO.0004 <br />MIN <br />F FINAL <br />5R&MINF DRNG rRIB )C .rl-;, ILE Im <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 />?- <br /> MEASUREMENT <br /> PERMIT .; <br /> `REQUIREMENT <br /> SAMPLE -' <br /> MEASUREMENT <br /> PERMIT I <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -l <br /> REQUIREMENT MIS <br /> SAMPLE -- <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT rc _ <br /> REQUIREMENT - <br />NAMEIMLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of lam that thi. d,K7munt and all auachments weer TELEPHONE DATE <br /> prepared under my direction or supea nion in accordance with a aystrm designed <br />,,pared <br /> : <br />that qualified pemamrl proprri? galher and evaluate the informatiom - - - <br /> .uhmitttd. Hawed on m% inquiry of the pe"m or perw , who manage the -tem. <br />- -- nr the pennas directly re,pot>sible for gathrrin¢ the information. the infarnatit n <br /> subrailled is, to the lies' or my knowlydlar and hadieL trvt•. accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE r _ <br /> I am aware that there are signirkmnl penaltit, For submitting rode information. <br />r knowi <br />sial <br />i <br />m <br />ni f <br />tio <br />ib <br />li <br />r ra <br />d i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPED OR PRINTED mpr <br />son <br />r <br />o <br />ng <br />a <br />ns. <br />itnlu ding the ptm. <br />i <br />ty o <br />nt an C D <br />GUMMCIV I J AIVL! CAI'LAINA I 1UN Ur Mill <br />I rIG/Cl CII{.C 0II OaaoN,ta,aO,aaJ tutu c-? <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used