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PERMITTEE NAME/ADDRESS elnclude Facifi¢.Yamelhwation if M ferenu <br />NAME <br />ADDRESS <br />BOX 670 <br />J <br />FACILITY <br />LOCATION <br />•J <br />-R <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NU7MB7E7R7A DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />M zNO <br />(SUS <br />F -- <br />DiSG <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE I i I <br /> MEASUREMENT <br /> PERMIT .,- <br /> REQUIREMENT <br /> SAMPLE r - - i --7 <br />( l / <br /> MEASUREMENT r` <br /> PERMIT r - <br /> REQUIREMENT <br /> SAMPLE I?e <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 cerury under penalty of law that this deKument and all attachmrnts were <br />ti <br />i <br />cc <br />rd <br />with <br />d <br />d <br />di <br />• <br />i <br />i <br />t <br />d <br />i <br />d ) TELEPHONE DATE <br /> prepare <br />er nn <br />rec <br />on or sufa <br />n <br />on <br />n a <br />o <br />ancr <br />a sys <br />em <br />es <br />gne <br />un <br />s <br /> n) a urr that qualified pe-ti d prutKrls gather and realuate the informnlieat <br /> %uhmitted. Based nn m.i inquin of the wrwn or persons who manage the system, <br /> or them per+eons dirrcth r-pmsiblr for gathering the information, the information <br />, <br /> suhmitted is, In the hra ed m) knonlydge and IKlief, true, accurate. and compk•tr. <br />w <br />h <br />h <br />- <br />i <br />t <br />lti <br />f <br />h <br />itti <br />i <br />6. <br />n <br />ti <br />n <br />I <br />ifi <br />f <br />l <br />SIGN URE OF PRINCIPAL EXECUTIVE ,- l- - <br />- <br />TYPED OR PRINTED unI a <br />are I <br />al t <br />:ere <br />can <br />pena <br />or w <br />m <br />ng <br />n <br />n <br />a <br />n <br />. <br />en <br />Ln <br />es <br />a <br />x <br />including Ittr 1-ibdn...I fine and imprisonment for knotting tiolatinns. O FICER OR AUTHORIZED AGENT A <br />CODE REA NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3(99) Previous editions may be used. This is a 4-part-- fortn.