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PERMITTEE NAMEMDDRESS(7-&&Farabry N--.?L.r.11-ttD(OW-0) <br />NAME <br />ADDRESS <br />FACILITY !YO <br />LOCATION R <br />INELLY <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM- JNPDESI <br />DISCHARGE MONITORING REPORT /DMRI <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 Inetmctlone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX Et1E0UENCV <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE =MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - t: ' - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT -"'' - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />J' l L f <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ;lei. r':_; i (. I 1 <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 />NAMEITiTLE PRINCIPAL EXECUTNE OFFICER t mmay under Pen. ty o law that this document and aft ubehmrnts were TELEPHONE DATE <br />p"pat'd antler my dlre,crton er super.hlon In accordance with a system deatgned <br />to assure that qualified personnel pr.",17 gather and e.aluate the Informs/ton <br />uir <br />or the <br />. - - ? nib <br />illed <br />Sawed on m <br />In <br />ersoa or <br />enoru who mana <br />e the s <br />stem <br />7 <br />q <br />y <br />p <br />p <br />g <br />m <br />. <br />y <br />, <br />or those persons directly -poedble for gathering the Informathm. the Information - ' <br />%?,-..-i ,, (•% ?._ submill cl Is. to the best of my knowledge and belief. true. orcvnle. and mmplet - <br />L <br />SIGNATURE OF PRINCWAL EXECUTIVE . <br /> I am .- that Ihe" a- atgnlfl"at penances for sstbmlttltsg hlse InformWun, A A <br />TYPED PRINTED Im4uding the poadblllty officer and Imprisonment for knowing etdathwes. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference dt etracnments here) <br />I F CL AIM nY WOl ,-V, <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-pan fonn. PAGE OF