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PERMITTEE NAME/ADDRESS f include Facility Namellocalion if Differs to <br />NAME _ <br />ADDRESS I' <br />FACILITY Zf?;': t t1?: <br />LOCATION C 1 A <br />pSl'F L!%.r•L=. i`i'i RIF MAi\iAnPR <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. 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 IS TYPE <br /> ANALYS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />z ?i .z <br />_ <br />% <br />_ <br />: x ;. ,. <br />r. <br />? . <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I `rrti(! under pemdts of law that this document and all attachments were TELEPHONE DATE <br />prepared under m.s direction or snpersision In Accordance with a system designed <br />to n,w a that yualiried petunnd properlc Mather and esaluate the infortmoitn <br />- -"? - submitted. auxd on m% inyuin of (fie Ix-on or penori% who manage the %)%tem. <br />- or those persons dlr-li., re,pon,ildr for gathering the information, the information <br />- submitted h, to the best of nn knowledge and belief, true, accurate. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am aware that there are signiftcunl penalties for submitting false information, <br />k <br />i <br />t <br />i OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED OR PRINTED nowing s <br />o <br />ons. <br />ut <br />including the persibilits of fine And imprisonment for D <br />COMMENTS AND EXPLANATION OI- ANY VIULA I IUNS (Ffererence au arracnmenrs nere/ <br />EPA Form 3320-1 (Rev T99) Prewous editions may be used <br />4HR PREO 3' P EVENT - 5;--E I . A. 2 , <br />30 DAY AVG IS HIGHEST NOWHL'Y <br />00556;