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PERMITTEE NAME/ADDRESS tinclude F'acilih Vamegocadon if Di/Jerrnu NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY L G:A..?-; MONITORING PERIOD <br />LOCATION FN G U 811-1 YEAR MO DAY YEAR O DA <br />FROM TO <br />KAf2T3, RFC!.AmA-T'IflN MANAG..: <br />Form Approved <br />OMB No 2040-0004 <br />MINC)F <br />(SUBIR <br />F - FI? <br />DISC; HANGt i-D JF'1i7i._?1`• <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 r y <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE J - - <br /> <br /> MEASUREMENT 1 <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ? j <br />r <br /> MEASUREMENT ` J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rertif) under 1-alt) orlaw that this diwmnent and all attachment, mere <br />d <br />d <br />i <br />i <br />i <br />i <br />ith <br />i <br />di <br />d <br />d <br />d TELEPHONE DATE <br /> on or supers <br />a »atem <br />: 'pam <br />un <br />er m) <br />rect <br />s <br />on <br />n accor <br />ance w <br />es <br />gne <br /> to assum that qualified penunnel properly gather and esaluate the information <br /> ,uhmitted. Rind on m) inquire of the per on or person. who manage the system. l <br /> or those persons directh responsible for gathcring the information. the information - <br /> submitted is. to the bc.t of m) knowledgr and bs•hef, true. accurate, and complete. $IGNATU E OF PRINCIPAL EXECUTIVE I - ' J <br /> <br />TYPED OR PRINTED I am aware that there are significant penallies for submitting false information. <br />including the possibilih of fine and impris mment for knowing %it,Wions. <br />OFFI R OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />GOMMEN15 ANU LXPLANAIJUN OF ANY VIULAIIVIVJ (deference an arracnmenrs nere/ <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. ='?"? -Thi,' is 4 Pad, fonn.