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PERMITTEE NAME/ADDRESS andl*&FadBtyNsm?Loeattnm VD(dirremf) <br />NAME <br />ADDRESS z. <br />FACILITY _ <br />LOCATION, <br />NATIONAL POLLUTANT MSCHARGE ELIMINATION SYSTEM //NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMSER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO_ DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />t <br />.. `? <br />NOTE: Reed Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br /> ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />6 <br /> MEASUREMENT ` L) <br />, W <br />7 <br />J <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT - - <br />Ott 10 <br /> <br />1 <br /> <br />? <br /> ?' <br /> PERMIT <br /> REQUIREMENT <br /> <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 /> SAMPLE <br /> MEASUREMENT <br />- ? } <br /> <br />>_ , <br />PERMIT <br />- <br />- - - <br /> REQUIREMENT <br /> <br />IMAME/TITLE PRINCIPAL EXECUTIVE OFFICER i certify u er pent ty o taw that this document and alt attachments were <br /> <br />prepared under my direction or supervision In accordance with • system designed <br />Y <br />A t I ?e <br />TELEPHONE <br />DATE <br /> <br />to assure that qualified personnel property gather and evaluate the information w <br />V?777?, <br />- submitted. Based on my Inquiry of On person or persons who manage the system, - <br />or those persons directly responsible for gathering the Information, the Information O <br /> submitted 66 to the best of my knowledge and belief, true, accurate, and complete. 9 <br />n ('? V- I am aware that there are signlfimnt penalties for submittin <br />false Information SIGNATURE OF PRINCIPAL EXECUTIVE 101 ZOE <br /> g <br />, REA - <br />- <br />TYPED OR PRINTED Including the possibility of fine and Imprisonment for knowing v!Watiomn OFFICER OR AUTHORIZED AGENT CO <br />DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA I IONS fRererence en errecnrnenrs hare) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. TYIIS lS i 4 Raft :IOrm. PAGE OF