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PERMITTEE NAME/ADDRESS !Include FaeilitY.Yamr/Gtrauion if Differemi <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />V. AR C1, Pr-,-I AMA T TCIW ViANAGFR <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 />T OMB No. 2040-0004 <br />M1114 LI <br />c Sul r '" '' <br />1= - <br />NOTE: Read Instructions before"completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 y <br /> REQUIREMENT <br /> SAMPLE <br />t MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />LJF <br />` I <br /> REQUIREMENT ;:.-y <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER certifj undrr penalh of law that this d--un.etn and all alluahmenls were <br /> <br />red und <br />directio <br />s <br />si <br />re <br />r <br />• <br />i <br />n in <br />c <br />with <br />0e <br />dei <br />d <br />d <br />TELEPHONE <br />DATE <br /> p <br />pa <br />e <br />m% <br />n or <br />ulx <br />r <br />s <br />o <br />cor <br />anrc <br />a %y <br />m <br />gne <br />a ?.. <br />\ <br /> to amum that quuhfird prnounel proprfls gather and esaluatr the inrormation <br /> submitlerl. cased on m? inyuin of the per`on or per.nn who manage the s)slem, <br /> or those lx•rwms dineUr re. pnntMe fur gathering the information. the infornmtiam <br /> •uhmiued is. Io the frost of ms knowh'dge and helhd, art., aeeurute. and rnmpla•tr. ' <br /> I am aware that them are significant penalties ror submitting false information, SIGNATU E OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED including the I-ibilit.% of fine and imprisonment rue knowing siadathms. OFFIC R OR AUTHORIZED AGENT AREA CODENUMBER YEAR MO DAY <br />UUMMtN I .5 ANN r-ArLNIV/1I Ivrt yr /11Y <br />Irtererence an arfacnmerns nere/ <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. ?tj = This is a 4-partfOrm.