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PERMITTEE NAMEIADDRESSp,..A-&Fer*yNw?L--im((Dtf--d) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /INPOES) <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 />NOTE: Reed Ir»tlructlorr bisforts, complotinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREGUENCY <br />OF SAMPLE <br /> <br />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 <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 />PERMIT <br />REQUIREMENT <br /> <br />NAMEfnnE PRINCIPAL EXECUTWE OFFICER 1 -""y " er i ly ° Is. that that d«,menl arse .n.u.eh.n.nu..e. TELEPHONE <br />l <br />l <br />l <br />t <br />t DATE <br />on w superv <br />prepared ender my d <br />rect <br />ston <br />o .tcordanre wtln , sys <br />em deltned <br />lln <br />nnel <br />ert <br />valu <br />the Infnrnl <br />t <br />s. <br />re th <br />t <br />u <br />d <br />e <br />r <br />ather <br />nd <br />t <br />ll <br />op <br />o a <br />a <br />a <br />q <br />a <br />e <br />p <br />rso <br />p <br />y g <br />a <br />e <br />a <br />e <br />a <br />on <br />sebmilled. Based on my Inq.lry of the pirmon or prmons No manage the system. <br />ar those pence dlrerlly mapomlble for gathtrtng the Inrormalleo <br />the Infornutlon <br />, <br />, <br />b <br />t <br />f m <br />kn <br />d <br />i <br />le <br />h <br />l <br />d <br />lW <br />d - <br />' <br />e <br />o <br />y <br />ow <br />ge an <br />sabmllled <br />. to t <br />e <br />e <br />bc <br />. trot. nomm <br />t. an <br />complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />i <br />n <br />l <br />I <br /> I am aware diet then an> <br />gN <br />cant prostate for wtbm <br />tatrlg rase <br />nrormatlon. <br />TYPED PRINTED Inrhnftng the p.sdblllly of n- and Imprison eratt for knowing tfolauce OFFICER OR AUTHORIZED AGENT CODE NUMEIER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rdorenc• NY •ttacnments hire) f += C L A T f'" A= P f` C. 1,v --' P,'.; W sC l- <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used This is a 4-pan form. PAGE OF