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PERMITTEE NAME/ADDRESS 4ricfrtde Facility A'amr/Location if!)ifferenti <br />NAME <br />ADDRESS IL <br />• °•2>=3 <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMR) <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 />MIP' - <br />M - l IV T ER I I`i i-ii•d <br />°.iR&MIN DRTQG TO CALANI i•Y DRAW <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 <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ` <br /> PERMIT :.. ?. ;, <br /> REQUIREMENT .-; <br /> SAMPLE <br />A <br />REM <br /> ME <br />ENT <br />SU <br /> PERMIT - <br /> REQUIREMENT r?iY i L <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT v <br /> REQUIREMENT i;rr= <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 Irenally of law that thk document and all altachmrnts am <br />i <br />k <br />c <br />with <br />t <br />di <br />i <br />i <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> on or supen <br />n Accor <br />an <br />e <br />a sys <br />em <br />gne <br />prepared under m) <br />rect <br />s <br />m <br />es <br /> to insure that qualified prr%onnel prola•rly gather and esahoar the information - - - - <br /> submitted. Based on m% inquire of the person or Persons who manage the system. <br />- " - or those Person, directly responsible for gathering the information. the information _ <br /> <br />" - submtued k, to the hest of my knowledge and belief. true. Accurate. and complete. <br />i <br />if <br />lti <br />iltt <br />r <br />h <br />t <br />f <br />h <br />l <br />I <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> gn <br />ican <br />pena <br />or su <br />m <br />ng <br />a <br />n <br />orma <br />on. <br />I am aware that t <br />en Are s <br />" <br />,v OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the f-ibilin of fine: and imprisonment for knowing siolatlons. ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attacnments nere) <br />I <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-par IT form. PAGE