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KFIMITTEE NAME/ADDRESSpt.r"Fwr?NyN--L -fia (/D(Q..wu) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /INPOESI <br />DISCHARGE MONITORING REPORT /OMR/ <br />PERMIT NUMBER F,--,,..,GE 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 Imtructione bo we completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. UENCY <br />FRE0 SAMPLE <br /> 0 <br /> EX ANALYSIS TYPE <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 /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMErnnE PRINCIPAL EXECUTIVE OFFICER i fer,ry " r p'"• y o low that this docament and all attachments were TELEPHONE DATE <br />prepared ruder my direction or superel>fow In accoedance with • >Tslem dtsigned <br />to assure that quallned personnel property gather and evaluate the InformalWn <br />submitted. Based on my Inquiry of the person or persona who manage the system <br />or thtser per>onr direrty respo,wbit for gathering the inrorsnauon the information <br />ci ? <br />,, . <br />.. <br />. •: !_ submitted is. to the best of my knowledge and beget, irur. nearste, and complete- <br />. <br />. <br />, <br />t am .war, that (here arr tignmrant prnaltlet rnr mbmiQin <br />raise Information <br />t10NATVRE Of PRtNCNAI EXFCtlTtVE <br />TYPED OR PRINTED g <br />, <br />inrtudtng the poedbitity 0 erne nd imprisonment rw knowing rle sdom OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reference ale attachment: hers/ <br /> <br />EPA Form 3320-1 (Rev 3199) Previous ed bons may be used This is a 4-pan form.