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r`EAMITTEE NAME/ADDRESSp.¦b6s -A*Jv. WLaeauae((DWFP--f) <br />NAME <br />ADDRESS 'Tt <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHARGE ELIMINATION SYSTEM ((NPOESI <br />DISCHARGE MONITORING REPORT (OMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMS No 2040-0004 <br /> <br />NOTE: Read Inetructfone Wore completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREOOENCV <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />1-1111Y. r Penalty .(I.- that this d- ,%l and au allscfirnenls were <br /> <br />d TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />re <br />r <br />d n <br />di <br />tl <br />n <br />r <br />er+l>r <br />n to <br />d <br />ith <br />t <br />desi <br /> <br />DATE <br />p <br />pa <br />ow my <br />rer <br />o <br />mp <br />o <br />aeror <br />¦nee w <br />a s <br />s em <br />e <br />o <br />gne <br />to .sure that qu.nned pemo.nel properly gather and ee¦luale the Inf-tlon <br />y }I a1 i <br />aobm111ed. Based on mr InqulrT of the pelwn or pe rlotr who manage the fJrirrn <br />, <br />nr those penerr¦ directly rapofnlble foe gathering the Infor dom the Inf-lion <br />., ?. i .: .`^ >ubtnllted Is. to the bat of wtT YnewNdge and belief. troe. smut-aW and complete. <br />SIGNATURE OF MINCWAL EXECUTIVE <br />- I a <br />th <br />t th <br />a <br />i <br />ln <br />t <br />itl <br />b <br />rlti <br />f <br />l <br />I <br />f <br />tb <br />f <br />- <br /> m aware <br />a <br />ere <br />m s <br />gn <br />un <br />prus <br />or m <br />m <br />a <br />ornr <br />es <br />ng <br />se <br />n <br />n• # <br />TYPED OR PRINTED IneltMing the p.¦fbiulf or nne and Irnpriaomnent roe ?no.ing .1d¦tlerf¦ OFFICER OR AUTHORIZED AGENT 1 WCR <br />COD YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Roforence &N Wachment3 herol PREC ? P EVENT 15 C:'4i 111FU. j C LA T f <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used THIS IS a 4-part fonn. PAGE OF