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PERMITTEE NAMEJADDRESS NncluJeFuciAn NameL,KuriontfDq?en•ni <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION ; <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER K;'_- +I? <br />MONITORING PERIOD WASH <br />YEAR MO DAY YEAR MO DAY <br />FROM TO ' <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np. FREQUENCY <br />OF SAMPLE <br /> EX ALYSIS <br />A TYPE <br /> N <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />- ; REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT a <br /> REQUIREMENT <br />i <br /> SAMPLE t <br /> MEASUREMENT <br /> <br /> PERMIT <br /> } <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .., <br />_v . <br /> - a : ? <br /> PERMIT <br />_ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> 10 <br />t TN <br />. F; A <br /> PERMIT <br />')! REQUIREMENT <br /> ? <br />3 <br /> SAMPLE ' <br />L <br />-i MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t i f L. `( h <br /> REQUIREMENT ;' ? .';T (?s; i L <br />AME/TITLE PRINCIPAL EXECUTIVE OFFICER I certdy under penalty of law that this dot urncnt and all attachment was TELEPHONE DATE <br />N red under ms direction or vapen ision in accordance witb a sy<tem destgmd <br />re <br />?? -+•- pa <br />p <br />to assure that qualified personnel properl}- gather and evaluate the information <br />- ?' -- ?" - - submitted. Rased on m} inquiry of the pen on or persons %hu tttanage the system. <br />the mformanon <br />therin <br />the information <br />f <br />r <br />th• <br />ibl <br />di _ <br />^ '? ' " ?' ` - <br /> . <br />respons <br />ga <br />g <br />rec <br />e <br />o <br />ar those perwrts <br />d <br />l <br /> ete <br />comp <br />submmcd ii. to the best of my knowledge and belict. true. accurate, an SIGNATURE OF PRINCIPAL EXECUTIVE <br />_ I um aware that there are significant penalties for submitting false information. OFFICER OR AUTHORIZED AGENT AREA <br />Y <br />O <br />DAY <br />NTED of fine and imprisonment fit knowing •wiations. <br />th <br />o <br />ibilit <br />l <br />d CODE NUMBER EAR M <br />TYPED OR PRI y <br />e p <br />ss <br />u <br />ing <br />inc <br />COMMENTS AND EXPLANAI IUN Ur ANT VIULAI IUNJ IRUIVIVncr all attar. <br />EPA Form 3320-1 (Rev. 3i99t Previous editions may be used. <br />here) <br />iR PFF': "' r 4 l , p{i 3 Ff]R ?Pale I cMEt,{T? <br />I h,, 1,, a 4-part tnrn? PAGE OF