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rERMIT1EE NAME)AOINtESS()mils Fwriky N-.WLl .ri-tfD(fwrv) <br />NAME <br />ADDRESS <br />1 z FA - i <br />FACILITY UH'YD f•1 Ni <br />LOCAT1pN K C R <br />NATIONAL POLLUTANT DISCHAAOE ELIMINATION SYSTEM /ANDES/ <br />DISCHARGE MONITORING REPORT IDMR/ <br />PERMIT NUMBER asCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />i -' <br />NOTE: Read Iratrvctlone Wore complet" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX rFREOLIENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ALYSIS <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 rest,Iy uncle, pen' ly o law that this cl r nwm and all attachments wen <br />TELEPHONE <br />d <br />d <br />m <br />di <br />ti <br />n <br />r <br />er+fdon In <br />d <br />r. <br />with <br />tem de <br />i <br />ned <br />DATE <br />prepare <br />se <br />er <br />y <br />ree <br />o <br />sup <br />.[cor <br />a <br />ce <br />. sys <br />s <br />g <br />o <br />to assns- that quaBned personnel properly g.ther and esatu.le the Informaction <br />I <br />l <br />i <br />' <br />submilled. Bawd on my <br />nqu <br />ry of the person or persons who manage c <br />te system. <br />or Ihor persons dlrerlly responsible for g.lhering the Infor ailbn, the Infor-atlon <br />.. /? mbmllted Is, to the best of my knewledgr and ttlltf, true, seevnte. and complete. <br />SIGNATURE OF PRINCWAL EXECUTIVE <br /> I .m aware that There an signillcinl penalties for submitting raise Information. AREA <br />TYPED OR PRINTED Inehwint the possibility of line and ImprHomment roe knowing rlol.tloni OFFICER OR AUTHORIZED AGENT ODE NUMBER <br />C YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Roferonce all attachments hero) <br />EPA Form 3320.1 (Rev 3M) Previous editions may be used This is a 4-part form.