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PERMITTEE NAME/ADDRESS finr! aa• FurilJn .vvmr'/..K mlun r/D; jrrrrrtr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />NAME ` DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />ADDRESS \ <br />PERMIT NUMBER DISCHARGE NUMBER .:. RD LAN <br />MONITORING PERIOD WASH <br />FACILITY <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTF• Raarl Inatnrr•tinnc hafnra rmm.latinn thlR fnrm <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ?'- <br /> REQUIREMENT r9Oh( ri-, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />I? REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE LI J ' <br /> MEASUREMENT <br /> PERMIT ?. <br /> REQUIREMENT <br />ni n <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT I - <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law" that this document and ell amlchments wete TELEPHONE DATE <br />?- prepared under my direction or supers ision to accordance with a system deslgmd <br /> <br />' ?G- !f w assure that yualt6cd personnel propcrh gather and evaluate the information .---?? -- <br />- <br /> submitted- Based on my inquiry of the person or persons who manage the system. - <br />r - or three persons directly respcmable for gathcnng the mtbrmation, the utbtmtation - <br /> •.-uh-ucd u, to the best of my knowledge and belief, lnw. accurate, and complete. <br />I <br />d <br />t th <br />i <br />i <br />l <br />f <br />b <br />f <br />l SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I <br /> <br />r.e,....?.._ . _.._....._.... _ .......... n m.rrc <br />ra <br />ere are sign <br />f <br />cant pena <br />ties <br />or.u <br />mitting <br />a <br />se infomtanon. <br />u,l nl:rv t}rc pu,stbiht} of fine and impnsonment for knowing %iolanons <br />. <br />._. .. _ <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />CODE NUMBER <br /> <br />YEAR <br /> <br />MO <br />_ <br /> <br />DAY <br /> <br />HR RF-C <br />Form 3320-1 (Rev srss) Previous editions This is a 4-part form.