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PERMITTEE NAME/ADDRESS rbtclu& ForilLy.%ank/Lewljfion ffDiprrentr <br />NAME I <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 />F?pi,AN <br />A <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r Y. v WIC} Iftit`_?''rV <br /> REQUIREMENT X 1. 1`1U''i ?!_F•.IT;i <br /> SAMPLE L <br /> MEASUREMENT <br /> PERMIT 4 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :. r.• r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t <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 V. <br />NAME MTLE PRINCIPAL EXECUTIVE OFFICER I cenif) under penalty of lain that thu documcnt and all atwchmentx were TELEPHONE DATE <br /> prepared under my direction or supen tsron m accordance with a system designed <br />_ <br />)! tr-/ r <br />- ? to assure that yrralified personnel properly gather and evaluate the mfom anon <br />h <br />• <br />" <br /> e system, <br />submitted d Based on my inquiry of the petcon or persons who manage t <br />or tlwsc persons dirc<tly responsible for gathering the information. the information <br />-. <br />- <br />- ? <br /> f <br />d <br />?- , subm ncd is, to the best of my knowledge and belie <br />, true, accurate, an <br />complete <br />f <br />i <br />l <br />b <br />l <br />i <br />t SIGNATURE OF PRINCIPAL EXECUTIVE <br /> a <br />se <br />o matwn <br />airs a++a a that there are signif <br />cant pena <br />ties for su <br />mitting <br />n <br />b <br />i <br />d <br />d <br />ti <br />l <br />n <br />k OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED ne an <br />tmp <br />sonmcnt for <br />nowing ou <br />a <br />ors <br />m ?•:du _ the possi <br />i <br />ity of f CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Hererence an arracnmenrs nere) <br />i AR PRE <br />SAMP L <br />FOR REOVIRFM <br />14. <br />EPA Form 3320.1 (Rev. 3199) Previous editions may De used. 0017S , This is a 4-part fomi.