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I'EHMITTEE NAMElAUUHESS linclade Facilip.Aamr/l.acarion if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION t t" } 3 <br />IR0, RE(,!-A i,ATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approv <br />OMB No 204 ed. <br />0-0004 <br /> r <br />F - F- Ii' <br />Li9CFIG . Li i r' li_ ' nil <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 <br /> MEASUREMENT J IU <br /> PERMIT <br /> REQUIREMENT = <br /> SAMPLE - j <br /> MEASUREMENT I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />l <br /> MEASUREMENT J <br /> PERMIT <br /> REQUIREMENT <br />IE <br /> SAMPLE <br /> MEASUREMENT J <br /> PERMIT <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I ocrtif% „rider pertain of law that this document and all attachments were <br />i <br />di <br />i <br />i <br />I <br />d <br />h <br />d <br />i <br />d TELEPHONE DATE <br /> prepared under my <br />rection or cupen <br />s <br />on <br />n aecor <br />ance w <br />t <br />a system <br />es <br />gne <br /> to assure that qualified personnel properly gather and esaluate the information <br /> submitted. Based on m) inquire of the person or penon% who manage the system. J <br /> or those prnons directl% responsible (or gathering the information. the information I <br /> submitted h, to the bast of my knowledge and belie(, tnx, accurate, and entnpletc. $IGNAT RE OF PRINCIPAL EXECUTIVE - ?? <br /> <br />TYPED OR PRINTED lam aware that them are signincam penalties bir -bmntin4 false information, <br />including the pscihilits of fine and imprisonment Ga kn,n,mG sn lulion,. <br />OFF ER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. nis i1 a 4-part form.