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FERMiTTEE NAMEJADDRESS (7webnfr farWey Na.WL wlaw /D(06 wr) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM J(NPOES) <br />DISCHARGE MONITORING REPORT IDMR) <br />PERMIT NUMBER DISCHARGE NUM/E14 <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MID DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br /> <br />NOTE: Read Irntructlom before completlnp this fofm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <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 ",Illy ° r pone y o aw chat Ulf document and all attachmatb were TELEPHONE <br />d <br />l DATE <br />Prepared and- my <br />irection or wjer-tshm In accordance w <br />lh a systetn designed <br />1 to assort that qualified personnel properly gather and e•alu-Ie the Informallm <br />fobmllled. Bawd nn my inquiry of Ne person w personal who manage tM .yu m, <br />' <br />or (hone persme directly responsible rw gathering the Infonrtallnn, the Informallnn <br />t <br />itt <br />t <br />th <br />f m <br />Lw <br />wyd <br />d b <br />I <br />b <br />d b <br />b <br />t <br />l <br />s <br />y <br />_ w <br />e <br />es <br />o <br />gr an <br />m <br />e <br />, <br />o <br />o <br />o <br />e <br />, <br />ron, accurate. and rompkte. <br />aware th <br />nrn <br />nnt <br />SIGNATURE OF PRINCMAL EXECUTIVE <br />I <br />t ther <br />l <br />ln <br />b <br />ltd <br />f <br />l <br />I <br />f <br />d <br />f <br /> am <br />a <br />e an s <br />g <br />r <br />prna <br />v <br />or su <br />m <br />ng <br />a <br />w <br />n <br />orno <br />on, ARE <br />TYPED OR PRINTED Including the podbnlty or f1w and Imprisuntnenl for knowing •Idathlem OFFICER OR AUTHORIZED AGENT COD£ NUM( R YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Ra/oronce uric attachments hero/ <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF