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PERMITTEE NAME/ADDRESS (include Facilifr VamelLocarian if Diffrrrnti NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY Y AR MO DAY <br />LOCATION BEN i-t;• g;" FROM TO <br />r KARO, RECL_AMt%TICJN MANAGE <br />MINOR <br />SUOR JC ) <br />F - FINAL <br />DSCHG TO TF <br />Form Approved. <br />OMB No 2040-0004 <br />! to <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif.,, under 1-1th of law that this d-utneni and all attachments were <br />ti <br />io <br />with <br />s <br />t <br />d <br />d <br />di <br />si <br />i <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> prepare <br />on nr super <br />c <br />n <br />n accor <br />ance <br />s <br />ent <br />gne <br />un <br />er - <br />rec <br />a s <br />es <br /> to a-um that qualified persimnet pr,"rh gather and eeuluate the information \I <br /> submitted. Based on m? inquire of the penun or poi ns who manage the system. i <br /> or thus,- penom dincdb responsible for gathering 1he Informalioa. the information , t <br /> submitted is, to the hest of no, know ledge and belief, true. accurate. and compiete. <br />i <br />f <br />SIGNATU E OF PRINCIPAL EXECUTIVE <br /> I am aware that there am significant Penalties for subm <br />tting <br />alse infnrmafiim. I <br />TH <br />I <br />A <br />NT AREA <br />TYPED OR PRINTED including the rx-ibilio of fine and imprisonment for knowing siofalioos. OFF <br />CER OR AU <br />OR <br />ZED <br />GE NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Thi,, is, a 4-part foml. PAGE OF <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used