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PERMITTEE NAME/ADDRESS (Include Facility NameAocation if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION { F I i i' Z; } 6 3 <br />Mr;i+iJ. RF:CL.A''1ATIOI\i M.AI`4A -ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />IF <br />DISt.J-it- RGE= f:a :?F+GE. i Rc-i=ii <br />NOTE: Read Instrur-tinns hafnra r_mmnlatinn thin fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />i <br /> SAMPLE <br /> MEAS <br />REME <br />T I <br /> U <br />N <br /> PERMIT -1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT <br />?. I <br /> PERMIT <br /> REQUIREMENT <br />I I I <br /> SAMPLE <br /> MEASUREMENT i <br /> PERMIT r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> NTJ <br />NAMEf ITLE PRINCIPAL EXECUTIVE OFFICER I ,rrtir? under penalty of la% that Ihi, dotumenl and all attachments were <br />d u <br />d <br />r <br />di <br />i <br />d TELEPHONE DATE <br /> Prepare <br />n <br />m? <br />e <br />rect <br />on or supertislon in accor <br />ance with u system designed <br /> to assure that qualirlal Pe nnri pru{xrly gather and e%aluate the infnrmaliou I <br /> submitted. Rir rtl on ms inquire of the person or perwons who manage the system, <br /> or those penons di"'d!1 responsible for gathering the information. the information <br />, <br /> .ohm itted is- to the best of m> knnwlydge and belief. Irur. accurate. and complete. <br />I am awarr that there are.i <br />nific <br />lties for sub <br />t <br />ittin <br />i <br />f <br />l <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE - <br />- <br /> <br />TYPED OR PRINTED <br />nisuu?.rn A- -Ml A\I AT1^- ear AAIV .nrse g <br />an <br />pena <br />m <br />g <br />u <br />n <br />ormat <br />a <br />on. <br />inclodinp the p.wsibiRls of Rnr and mlpris mment for knowing,iotatiom. <br />A-1- <br />OFFICER R AUTHORIZED AGENT <br />CREEA NUMBER <br />YEAR <br />MO <br />DAY <br />tER C <br />EPA Form 3320-1 (Rev. 31991 Previous editions may be used This is 8 -(oaf( fnf-Itt, PAGE OF