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PERMITTEE NAME/ADDRESS (Rn&?&Jr. i*ty Na w(Ler.e/ow (/DtoGem) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM //NVPDESJ <br />DISCHARGE MONITORING REPORT IDMRJ <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 Instructions before completing this fwm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FRECUENCY SAMPLE <br /> OF <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 /> <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 />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I nrt'ly ° penalty law that Ihh dersment and all .11sehmenls were ?ELEPHONE DATE <br />prepared ender my dtrectlon or sup-hlon In arcordanre with . system designed <br />?r L L to enure that quallned personnel property gather and eeah'ate the Infornnlbn <br />L submitted. Based on my Inquiry of the person or pry who manare tM system. <br />ar those persons dlrrrtlr responsible for gathering the Information. the Inforntati n <br />t <br />f <br />k <br />led <br />b <br />it <br />d I <br />th <br />b <br />su <br />my <br />now <br />m <br />te <br />s. to <br />e <br />es <br />o <br />ge and better, ime. arrurate, and complete - <br />' I am swan that these an significant penalties for wrbrniRln <br />raker lnfonnaaon <br />SIONATURE OF PRINCIPAL EXECUTIVE <br /> g <br />, <br />ln <br />l <br />I <br />i <br />t <br />f fi <br />i AAEA <br />TYPED OR PRINTED r <br />ne and <br />ud <br />ng <br />he Possibility o <br />mpr <br />sonment for knowing rldauoru OFFICER OR AUTHORIZED AGENT <br /> <br />NUMBER <br />C <br />OOS <br />I <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION Or ANT VIOLA I IONS (RNermcs sd sttscinments hers/ <br />:P E%FnAT T?- CI_??MEP.. IF CI AIM !.!^Cr <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan form. PAGE OF