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PERMITTEE NAME/ADDRESSpeitf.f«ifflr?..rLer«aw1/D?eer v), <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTEM NPDES/ <br />DISCHARGE MONITORING REPORT ID RI <br />PERMIT NUMBER D43CHAAOE NLUBER <br />MONITORING PERIOD <br />YEAR MO DAY F- I YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read Instructions Woe* completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br /> EX MIALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEfI TLE PRINCIPAL EXECUTIVE OFFICER t "r"y ' a"'Ito Ie+ that this donemrnt ere .M ettaMmmis wrrr <br />TELEPHONE <br />DATE <br />Prepared under my dlrectlon or wP-k>1on In treoed arcs with a sy.lem designed <br />to avure that quehflM personnel properly gather end r-luate the Information <br />submitted. Sawed an my IrputrT of the person or prraone who manage the systern, <br />or those persons directly respoerelble for gathering the Information. Ike Information <br />mbrtelted Is. to the bat of me knowledge end beMef, urns, accurate, and complete. <br />I ¦m swan that there are slgnlncont Penal= for aubmttting raker Intormation <br />SIGNATURE OF tM11NCMAl EXECUTIVE <br />- - <br /> <br />D , <br />Includin <br />th <br />ibilit <br />f e <br />d I <br />i AW <br />TYPED OR PRINTE g <br />e poss <br />re an <br />y o <br />mpr <br />sonment for knowing .folstlorm OFFICER OR AUTHORIZED AGENT COOS NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Refaranca aN atfachmonta hors) <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used 1 -his 15 a 4-part fOrm-