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PERMITTEE NAME/ADDRESS <br />pnrrrFwrMiryNw?l,errowl/D?i.na) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTIDA //NPOES/ <br />DISCHARGE MONITORING REPORT (OMR) <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: Read Instruetlonn before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />of SAMPLE <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 /> 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 />NAMElfITLE PRINCIPAL EXECUTNE OFFICER I -Illy • er pen, ty, Iaw that Ihh do jrnrnt and all stiachmentr were TELEPHONE DATE <br />prepared antler my diretlion or mite felon In accordant with a system designed <br />to avarc that gaaNned perwnnN Popod7 Lather and evaluate the <br />Information ,/ <br />fabmllted <br />Fred m my Inquiry of the peria i a <br />en who man <br />e th <br />trm <br />. <br />p <br />g <br />e srr <br />, _ <br />w th <br />il <br />-Mbl <br />rso <br />di <br />- <br />f <br />ath <br />i <br />I <br />f <br />i <br />th <br />th <br />p <br />ose pe <br />rte <br />rt <br />y <br />e <br />or g <br />er <br />ng <br />n <br />e <br />ormat <br />on, <br />e Information <br />submitted ta <br />the best of m <br />knowled <br />I <br />d b <br />W <br />l <br />t <br />d <br />i i ?I L• <br />y <br />. <br />, <br />ge an <br />e <br />. <br />rot, atcun <br />e. an <br />ecmpleir. <br />= f- ' I ,maw- tbat there ¦m slofk.nt penalties for mbmitnn <br />nbr Information <br />SIGNATURE OF PRINCMAL EXECUTTVE <br />TYPED OR PRINTED g <br />, <br />InchWing the poadbillty of tine and Imprisonment for knowing vielaUorl>; OFFICER OR AUTHORIZED AGENT CAREA ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rulairence aBat(schmentshorn) ?'REC:IP EVENT IS CLAIMED. I1- -L-AIM APPRII `Y <br /> <br /> <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This i5 a 4-part form. PAGE OF