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PERMITTEE NAMElADDRESS,1n. hide facilih Xame'lwx urum'f Diffemnl) <br />NAME <br />ADDRESS <br />FACILITY l l <br />LOCATION <br />Form Approved. POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB Na. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREDUENCY <br />OF <br />AN <br />LYSIS SAMPLE <br /> <br />TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />l i <br /> SAMPLE <br /> MEASUREMENT <br /> ' <br /> PERMIT <br />REQUIREMENT v <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />- PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> <br />- - b_i;• PERMIT <br /> <br />REQUIREMENT <br />. <br />t, <br /> SAMPLE <br />: MEASUREMENT <br />Ti. <br /> <br />_ F PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />-c <br />PERMIT r } ,r n a FCS r:?. <br />REQUIREMENT t <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1-11f. under {malty of law that this document and all attachments were TELEPHONE <br />_ pr spared under my direction or super ision in accordance with a system designed <br /> <br /> <br />ATE <br />+'. to assure that qualified pcrKmnel properly Bath K and esaluate the infor nation <br />- submitted. Based on my inquiry of the person or person, who manage the,y,tanr. <br />or those parson, dirc.tl, responsible for gathering the information, the information _ <br />submitted is. to the best t f my knt)%Iedge mid belief. true, accurate. and completr SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />-' <br /> I am aware that there arc significant penalties for cuhmtung false information. <br /> <br />OFFICER OR AUTHORIZED AGENT <br />MBER <br />DE <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the possihihty of fine and imprisonment for know mg ,iohuum,. NU <br />CO <br />COMMENTS ANU LAF'L,ANA11UN Ur ANT vlvu+11v1Na Inc/c1c11- an a..o,...... <br />EPA Form 3320-1 (Rev. 1%) Previous editions may De used. <br />PREC IP. EVENT - SEI <br />AM-P±.- 7 NG I W)'T . UC T 10Nc. <br />PAGE Or