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PERMITTEE NAME/ADDRESS(7-d6&sar&tl N--VL-atfan((D(f wr) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHMOE ELIMINATION SYSTEM NPOESJ <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER aSC.ARGE Nt1MBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />0108 No 2040-0004 <br />NOTE: Read IneHVctlorw before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT _ <br /> <br /> PERMIT <br /> REQUIREMENT N ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />- <br />:1 <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT r/`yJ t?, J <br /> PERMIT <br />R <br />ENT <br /> REQUI <br />EM <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ` <br />i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME)TITLE PRINCIPAL EXECMWE OFFICER ' ren"y under -pena'y o aw that thH doeoment and at .ttachmenn were <br />TELEPHONE <br />DATE <br />prepared rider my directlow a suPer.1>ton In arcnM.nce w11A • system designed <br />• /??yi to Arum that qualified personnel property gat Mr and rrabate the InrormaHon . <br />submitted <br />Bred nn m <br />In <br />uir <br />o! th <br />r <br />o <br />or <br />e <br />wh <br />. <br />q <br />y <br />y <br />e pe <br />s <br />n <br />p <br />rson <br />o manage tM system, <br />or those persore directly responsible foe gathertnt the Information, the Informatbn <br />submitted is, to the bet of my knowledte and It~ tr, er..ecorste• and compkte. <br />I am swan that there am slgnlncant Penalties for submittin <br />rate tnformatlon <br />SIGNATURE OF PRINCNAL EXECUTIVE <br /> g <br />, <br />Incl <br />dl <br />th <br />il <br />f Il <br />i <br />t <br />d i <br />i A A <br />TYPED OR PRINTED nt <br />u <br />e Poss <br />b <br />i <br />y o <br />nr an <br />mpr <br />sonment for knowing rlolstlok OFFICER OR AUTHORIZED AGENT NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re%rence *# e((echmen(a here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This IS a 4-part form. PAGE OF