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PERMITTEE NAME/ADDRESSp-&,yFarMryNa. WL .elawl(D{eGwr) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEAA INPOESI <br />DISCHARGE MONITORING REPORT /DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO Y YEAR MO DAY <br />FROM DA TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read kistructlona bsfors complst" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FRE°0Y <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I C`rib'` " er penalty ° I.. that this docvrmnt and all.ttac tj were TELEPHONE DATE <br />Prepared "neer my dirvetlon or wper+i.lo. In wcord.rim with . %"I- designed <br />to a m that quaMM1ed personnel pro"Al Lather and ...iu.te the Inforwutlon r, <br />soemtned. Stated on my Inq"Irk of the person or penwr ho manage the rystrrn, <br />dble ( <br />th <br />f <br />ti <br />th <br />I <br />f <br />i <br />th <br />I <br />/i <br />w thou perums dimity mp.r <br />tx ga <br />er <br />ng <br />e <br />n <br />orma <br />on, <br />e <br />n <br />orm.tion <br />/ -- whmltted b, to the hnt °f m7 knowledge and hellef, imc sc-mle. and complete. <br />SIGNATURE OF PRINCIPAL EXECUT VE <br /> <br />' <br />. <br />- - 1 ...ware that then are etgnlfIcaM penalties for mbmltttng fate Info llon. ARE <br />TYPED OR PRINTED Inchrding the peaalblifty of fine and Imprfoon.ent for knowing .fdadorm OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reforenc• sd attachments hors) <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used. This i5 a 4-part form, PAGE OF