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PERMITTEE NAMFJADDRESS 0- && F.AIYhiass?Loa.rion (I Dt6irrent) <br />NAME <br />ADDRESS <br />FACILITY tJ Y 1_i 1`11 !V t <br />'. ER <br />LOCATION <br />7 <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 />NOTE: Read Instructions before completing this /ofm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />YPE <br /> ANAlrsts T <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 />NAME/TITIE PRINCIPAL EXECUTIVE OFFICER 1 nK"y " nckr penalty ° law that thii document and to attachments wen TELEPHONE <br />1 <br />d <br />d <br />di <br />i <br />I <br />t DATE <br />prepare <br />ar <br />.e my <br />- <br />n accord.- with . sys <br />rect <br />on or super- <br />em designee! <br />- <br />_ <br />- t to pure that qu.M M194 pereonnH property gather and er.lu.te the Info-natlon - <br />submitted. Bard nn my lnqulry of the person or prraom who mast." the system, _ i <br />oe those prewono dimity rvpowfbir far gathering the Information, the infornutlem <br />. <br />f '. `- rL submitted Is. to the best of my k-kdge and belief. true. ace iml,. and complete. <br />- I am <br />t th <br />re am si <br />.n.ie <br />is <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />wum th <br />nificant <br />f <br />sub <br />itnn <br />f <br />•nfor <br />n <br />tl <br /> s <br />a <br />e <br />g <br />p <br />es <br />or <br />m <br />g <br />. <br />. <br />ma <br />o <br />• AREA <br />TYPED ORPRIPITED tm°lath.gthepodbiutyotn°a.ndImprisonmentfo,knowing .Wworn, OFFICER OR AUTHORIZED AGENT CODE ??ER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ant attachments here! -, <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF