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PERMITTEE NAME/ADDRESS tlnclude Facility \'ame/Loration iiAiffrrentl <br />NAME .l 1q(„ L <br />ADDRESS <br />C.( c <br />FACILITY <br />LOCATION <br />I ANCr- lek -151E MANAGE <br />- '1FDESi <br />JiSCHAHGE I00kiTORING HEPORS (Oiv1R,) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <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 :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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I ceruf? under prnaltp of Iuw that this document and all attachment were TELEPHONE DATE <br /> prepared water m? direction or supen kion in accordance with a sysem designed <br /> lot assure that qualified la rsomad pruperl' Rather and esatuate the information - - <br /> submitted. Rased ors m) inyuin tar the person or prrsons who manage the system. <br /> or thane person. directly reepgmsibir for gathering; the information. the information <br /> submitted is. In the hest of m) knowledge and belief, true, accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- i <br />' I am aware that there are significant penalties s for submitting fake information. <br />i <br />ti <br />f <br />k <br />i <br />l OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED OR PRINTED, <br />I now <br />ng s <br />including the p»sibiliq of fine and imprisonment <br />or <br />a <br />a <br />om. CODE <br />CUMMtNI, ANU tAPLANAIIVrv Ur ANT VIVLAIIUM) (rfeterracr an attacnlnelns llCrC/ <br />EPA Form 3320-1 (Rev- 3199) Previous editions may be used Thk is a-4-part f6mi.