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Form Approved. <br />PERMITTEE NAME/ADDRESS ilnclude Facility Namelacation if Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) OMB No 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER ' N I ER 1 i <br />T0 CALAN,1 T 7 DR'C44 <br />MONITORING PERIOD <br />FACILITY YEAR MO DAY YEAR MO DAY <br />LOCATION ` - FROM TO ' <br />;- r- s. lnI- NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT >c a <br />A <br />, <br /> REQUIREMENT . <br />i <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> (? , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT • .. :. c .,.. ; _ ,1 T 1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> _ ., <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penau) of law that this dnvmenland u11 attachment, were <br />prepared tinderm? direction or supenisian in acrordunee wiW a system designed TELEPHONE DATE <br /> w assure that qualified perwnnd properly gather and esaluate the informatlon <br />-- <br />' submitted. Bused on m? inquiry of the person or pers,ms who manage the scytem. <br />msible fur gathering the information. the information <br />tl <br />n <br />di <br />r <br />s <br />h <br /> p <br />ine perso <br />s <br />rec <br />y <br />e <br />or t <br />I submitted h. to the first nt my knowledge and helief, intr. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - -- <br />" I am aware that there are %iguirwant penalties ror submitting false information. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the possibility of fine and imprisonment ror knowing.idnli ws. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence an arracnments nerej <br />2. <br />IED i= 1'lli ? O1'R, 24HR PREt" IP EVENT - SEE I. A. <br />This is a 4-partfbmi. PAGE OF <br />EPA Form 3320.1 (Rev. 3J99) Previous editions may be used.