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PERMITTEE NAME/ADDRESS Nnclnde Fardity Vamell oratien ijlhJJerenu <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />c,.3 <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 E- I <br />Form Approved. <br />OMB No. 2040-0004 <br />MINOR <br />t SUBR <br />F - F1 <br />DISCHA <br />NOTE: Read Instructions before completing this form. <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 /> <br />MEASUREMENT _ <br />--,. <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I <br /> SAMPLE <br /> MEASUREMENT j <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I <br /> PERMIT <br /> REQUIREMENT _ I <br /> SAMPLE <br /> <br />MEASUREMENT I <br /> PERMIT , . <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT 1 <br />I tJ 4?, <br /> PERMIT ;t <br /> REQUIREMENT <br />NAMEI ITLE PRINCIPAL EXECUTIVE OFFICER I "'I., under penulH oflaw that ihi%document .ind.dl attachment% merr <br />d <br />d <br />di <br />TELEPHONE <br />DATE <br /> prepare <br />un <br />er m% <br />rection or uper%Wou in accordance wnh -' lem de%igned <br /> to assure that yualiricd prnonnel properly gather and esatuate the information ' <br /> suhmitted. Bused on mi inquiry of the prrson or persona who manage the system. <br /> or those penons directly n,pmmsible for gathering the information, the Information <br /> mitt k. • the bra ms knowledge and belief. true accurate. and complete. <br /> I a <br />am aware Chat them are e significant <br />Bi <br />b <br />itti <br />r <br />f <br />l <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />TYPED OR PRINTED <br />COMMENTS EXPLANATION OF ANY VIO prrw <br />es <br />or su <br />m <br />se <br />ng <br />a <br />n <br />ormation. <br />including the possibilits of Fine and imprisonment for knowing flotations. <br />I OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />DE YEAR MO DAY <br />AND LAT ONS (Reterence all attachments here) <br />EPA Form 3320-1 (Rev 3199) Previous editions may t'ye used. Tbis is i3?4-part form. PAGE OF