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?'-RMITTEE NAME ADDRESS <br />NAME <br />ADDRESS _ L CIA'?01-IT <br />IVIfi ?I4 <br />FACILITY R DF - <br />LOCATION ::•N I A 14 <br />;"ES '. GCIOPER. ;"'PESIDENT <br />- -9 <br />ATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) J Form Approved. <br />N <br />DISCHARGE MONITORING REPORT (DMR) R ( OMB No. 2040-0004 <br />MH )? <br />PERMIT NUMBER DISCHARGE NUMBER I NqL ;.t _Tf3 <br />MONITORING PERIOD FORK GUNN I SON <br />YEAR MO DAY YEAR MO DAY <br />FROM TO kY;l <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. I FREQUENCY <br />OF SAMPLE <br /> ? TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT 9.0 E FV,L.. I _: ,. J <br /> REQUIREMENT f'I I h? ; MA X I MUM <br /> SAMPLE <br /> MEASUREMENT <br />- <br />- <br /> PERMIT ###v## }## ;t :. u ###-4 r 15, 70 71 M <br />71 ' <br /> REQUIREMENT _PODA AVG 1)AI!_'•( NX MONTH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT '? #'I# ilk „### u# #> #?1 REPOP.T O 5 Q NCE/ GRAB <br /> REQUIREMENT DA 11. MONTH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ####1! sIk'?### # . :... *Tlak' ## :3. 5 7 Q U NCF-/ a A <br />_ REQUIREMENT 30DA AVG DAIL`. 11? NIONThi <br /> SAMPLE , .. ., - t <br /> MEASUREMENT <br /> PERMIT ###3E ?tiF ilsk#lt# a : -:=? ?!###9IM ?. 5 7. G / > <br /> REQUIREMENT 30DA AVG DAILY MX 11r>: MONTH <br /> SAMPLE Tt.= ; #_k# t 9 1 <br /> MEASUREMENT <br /> PERMIT ###### ##;t### :? .#: ##?t##3F -f### ?# 10 t <br /> REQUIREMENT -- <br />C- <br /> SAMPLE 4'. <: 03 ) <br /> MEASUREMENT <br /> PERMIT uEPORT Rt.c-!; C 1 .. , ,. ,. <br /> REQUIREMENT .;ODA 0A I L Y 1`1:' <br />NAMETITLE PRINCIPAL EXECUTIVE OFFICER I .crtify. unckr pcnalq .flaw that utc document and all attachments were <br />i <br />h <br />l <br />d <br />, <br />di <br />i <br />i <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> prepare+ <br />rection or supcn <br />nn <br />n accor <br />ance wit <br />a system <br />es <br />un <br />er in <br />. <br />s <br />gne <br /> to as%urc that qualdied personnel properly gather and evaluate the miommatinn - -- - <br /> submmtted. Based on my inquiry of he person or persons who manage the system. <br />or those persons directly resporwhie for gathering the information <br />the information <br />- • '- - I / '? /e ; .'' / <br />_ <br />, <br />- <br /> <br />^ <br /> <br /> <br />" . <br />to the be <br />kn m ^ Icd <br />c and belief <br />true <br />uyumte <br />and com <br />lete <br />ubmitt <br />d i <br />t of m , <br />` <br />- ' `? i ) n <br />?7 <br />?+ C e T DE 'vl T , <br />. <br />e <br />s. <br />s <br />y <br />g <br />, <br />, <br />p <br />s <br />1 am aware that thcrc are significant <br />?malties for +ubmrmn <br />false mformauon SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />. <br />p <br />including the po.sihility of zinc and nnpnwnment for knowing violaumn. OFFICER OR AUTHORIZED AGENT AREA <br />CODF. NUMBER <br />YEAR <br />MO <br />DAY <br />UOMMtNI, ANU tXI LANAI IUN OF ANT VIULAI IUNJ (Kererence all arracnmenrs nere) <br />-HR PRECIP <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 000 13,,- C-.,-Tbi§ is--a,-4'part fonn.