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pEafAITTEE NAME,ADDRESS,L:,;.,. <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />';I;E. ? I:i•dt?-" i•if?TvAGE <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER T - <br />PERMIT ki <br />:E DRNG TO T UTTi.. E DRAW <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT !f'i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r. ;z f, <br />_ r't.•., <br />_ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />i REQUIREMENT 30DA C <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif. under Wriatt> or law that this dixumeni and all attachments were <br />rr <br />arrd und <br />r mr dir <br />ction or s <br />ervisio <br />re with a <br />str <br />i <br />ac <br />o <br />da <br />d <br />d <br />i TELEPHONE DATE <br /> p <br />p <br />e <br />e <br />up <br />n <br />n <br />c <br />r <br />n <br />sy <br />m <br />gne <br />rs . <br /> to assure that qualiriat personnel prnfwrf} gather and evaluate the information <br />' - -'- "- - --, submitted, Rased on ms inquire of the iwrv,n or peman% who mmnage the system. <br /> or those persons dimcdy re%p risible for gathenn t the information. the information <br /> suhntitz d is. In the hest of m <br />i km-ledge and belief. true, amumae. and complete. <br /> . <br />I um rw are that there are significant <br />enalties ror submitting raise information SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ <br />TYPED OR PRINTED P <br />. <br />Including thr p-sibilio or foe and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT <br />I AREA <br />NUMBER <br />CODE YEAR MO DAY <br />UUMMCIV IJ AIVU CAI'LANAI IUN Ur ANY VIULAI IVIVA Irrererence an arracnmenrs mere/ <br />:71 <br />EPA Form 3320.7 (Rev. 3199) Previous editions may be used. Thi5 1S a'4-part ?OTitl.