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PERMITTEE NAME)AODRESS (7--&k F.,M#y Na.WL.c.ii.w (/D(06ww) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />,LL <br />NATIONAL POLLUTANT OISCHMOE EUMINATION SYSTUA /INPOES) <br />DISCHARGE MONITORING REPORT IDMRI <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 irntructions before co+nplsting this tam. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br /> <br />EX FREOUENCY <br /> <br />of <br />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 />i ",illy under penalty or jaw that Ub doenimewt and all attachments were T <br />TELEPHONE <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER <br />i <br />DATE <br />prepared under my d <br />rection or sup-bilon In accordance with • system ddgnrd <br />to assure that quelilled personnel properly gather and evaluate the inlormatlon <br />!"? • submitted <br />Bawd ail my Inquiry of IM person or <br />ersore who mana <br />e the s <br />stem <br />. <br />p <br />g <br />y <br />, <br />or those Persons directly mpoidble fa gathering the Information, the Information _ <br />. _ ; ; ? f ?` submitted Is, t. the best of my knowledge and belief, true, accurate, and cornpkie. <br />nifi <br />SIGNATURE OF PRINCWAL EXECVTIVE <br />w <br />th <br />t th <br />i <br />nt <br />Iti <br />f <br />b <br />l-si <br />f <br />I <br />f <br />I <br />l - <br />- <br />TYPED OR PRINTED a <br />l aware <br />a <br />em are s <br />g <br />ca <br />pen. <br />e <br />or al <br />m <br />ng <br />o <br />>f <br />n <br />ormation, <br />lnciuding the pon-bility of flee and ImprMowwrnt for knowing vi.latlom OFFICER OR AUTHORIZED AGENT AREA <br />CODE AMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reference sat •ttechments hers/ <br />-n Tf" CLA-I.: <br />EPA Form 3320-1 (Rev 3199) Previous editions may he used. This iS 2 4-part Conn. PAGE OF