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PERMITTEE NAME/ADDRESS (include Facility NamelLocarinn if Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME C DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY i MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />ANC :. <br />Mir <br />(?( <br />M <br />LOS <br />Form Approved <br />OMB No 2040-OOU-l <br />1'l)'.) T, RS <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT R L.I t n :. - t I? c <br /> REQUIREMENT DA I L'T' Y <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ;: R ?k# r <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 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certiry under penal" of law that this document and all attachment., were TELEPHONE DATE <br /> prepared under rm direction or super, ision in accordarwe with u syaem drsigned <br /> to assure that qualified personnel properis Rather and rsaluatr the inrormation -- - <br />-- '-- - - -- - _ submitted. Based on my inquiry of the person or person. who manage the ssstem. <br /> or thosr persons dirrctly regamsible for gathering the information. the information -' <br /> , knowledge and belief <br />true <br />accurate <br />and com <br />lete <br />h <br />itim is <br />1. th <br />heel .( <br /> , <br />, <br />p <br />. <br />su <br />m <br />. <br />e <br />m <br />, <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />'- <br /> I am aware that them are.igutficant penaltle, ror.uhnutting false information. <br />r fi <br />i <br />si <br />l <br />ti <br />ihillt <br />d i <br />i <br />m r <br />k OFFICER OR AUTHORIZED AGENT <br />REA NUMBER <br />A <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED somnr <br />nr <br />now <br />ng <br />rms. <br />including the puss <br />y o <br />ne an <br />mpr <br />o <br />a CODE <br />UUMMLNIJ APW tAVLANA I IVIV Vf HIYT VIVLA I IV1YJ frTUIVIVI1(:C alit 11criv/ <br />1. TMT-r APP!_IFL• FnR 10Y9, ;?4HR PRF_C?P EVENT - SEE T. A 2. <br />EPA Form 3320-1 (Rev. 199) Previous editions may be used. TfPiS-1S':1 4-part fOrin. PAGE OF