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PERMITTEE NAME/ADDRESS (include Farifiti. ?mn, l -au„n q Afferrnr, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 />MIN OR <br />(SU BR JC <br />F - FINAL <br />SUR FACE RUNOFF I'D TROt <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• FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE [? 3Z t?? If.f ITJ <br /> MEASUREMENT <br /> PERMIT ; <br /> REQUIREMENT <br /> SAMPLE *ZA R <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r •..rC <br /> SAMPLE ,:- <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE i - g <br /> MEASUREMENT <br /> PERMIT ,. Vic; 1 n <br /> <br /> <br />IREMENT <br />REQU <br /> SAMPLE <br />L? <br />; <br />! <br />4 <br /> MEASUREMENT . <br />.. . <br /> PERMIT <br /> REQUIREMENT DA 1 i- i <br /> SAMPLE , (J(A N /A <br /> MEASUREMENT <br /> PERMIT <br />-. <br />t.i• <br />_. <br /> REQUIREMENT <br /> SAMPLE Oct <br />G 0I ? <br />0 YJ I J? l 1 J ?. <br /> MEASUREMENT . i <br />1 <br />, <br /> PERMIT _ , . <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certify tinder 1"'n.dt` of hr, that this document and all attachments were - TELEPHONE DATE <br />r prepared under my direction or supenision In accordance with a gstem desigmd __ - <br />\f? <br />' to aw are that qualified per-nael prnfterf} gather and es:duulr the information / _- <br />-teen. <br />?, <br />Ci T l +uhmitted. Nand on mt inq u or the Iw•rson ar persons obo manage the - <br /> or those Persons direcd mp,.nsihle for gathering thr infurmabom. the information -.? - I <br />, ' <br />•.. ,_ "_ <br />ompkte. <br />sit milled is, to the Iw+st d n s knowledge and M•licl, true. ucruralr. arid, <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />_1 J i - Ii? I? <br />- -' <br />._ i <br />-? <br /> I am aware that there are sm_nirw"unt Penalties for submitting false information. AREA <br /> siolations <br />d im <br />eni roc knowin <br />th <br />ihilit <br />f f <br />n <br />a <br />ri- <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED g <br />. <br />e ro- <br />i <br />e <br />n <br />p <br />m <br />nc <br />u <br />ng <br />io o D <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IUNS (Hererence an anacnmenfs nerej <br />n FOR REGI; I REMEN <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. 1111" is a .4 pt ilt It'll'