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PERMITTEE NAME/ADDRESS ilndudr Farihry.Yamell"ariat if Utfferenrl <br />NAME <br />ADDRESS <br />i <br />FACILITY <br />LOCATION <br />iv <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 />Form Approved <br />OMB No 2040.0004 <br />MINOR <br />( SUBR !1H) <br />M " 1N IER1iwl <br />--R&-M1Pic DRNG TO c_A <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FRE U Y SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT "'•- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT W f a :; s <br /> REQUIREMENT f; i R <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 certify under penalty of law that this d«vmeni and all attachments wen <br />i <br />: <br />i <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> -tion or suprrs <br />,m in accor <br />prepared under my d <br />s <br />ance w <br />t <br />a ystrm <br />es <br />gne <br /> to assure that qualified Personnel properly gather and esaluaw the information <br /> submitted. Based on m) inquire of the persan or prrsons who manage the ystrtn. <br /> or those perstns direcdy rrspmsBde fur gathering the information, thr information - <br /> to the bevel of rn knowledge and halirf <br />true <br />-vurale, and complete. <br />submitted is <br /> <br />- " , <br />, <br />, <br />h <br />h <br />i <br />ir <br />l <br />i <br />i <br />i <br />r <br />i <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE " <br /> <br />TYPED OR PRINTED I :,m awun• t <br />at t <br />ere err s <br />gn <br />icant pena <br />t <br />es for suhm <br />tt <br />ng <br />a <br />se <br />n <br />orma <br />on. <br />iwiuding the passibility orfne and impri. nntent for knowing ri,dutions OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />CUMMtN I b AND tXNLANATIUN OF ANY VIULA I IUNJ (Mererence an affacrtmenfs nere) <br />L.IM I T APPL I ED FOR OYR, a 4.HR PREC f rt•;' EVENT - SE i- 1. A. 2, <br />-IONS -- 1. C. :U, PG. 30 DAY AVG IS HIGHEST MONTHLY <br />YAW: OF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions maY be used.1i8 IS a'4-pan fOitll.