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PERMITTEE NAME/ADDRESS Unclude ForiGh \'ame/Lorarion if Different) <br />NAME <br />ADDRESS <br />FACILITY _ . F <br />LOCATION L? <br />v ?S <br />81 <br />ca 8163 <br />ON MANAGER <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 />MINOR <br />(SUER J <br />F - FIN <br />O1SCHAR <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TY <br /> ANALYSIS PE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE j <br /> MEASUREMENT -- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i ' <br /> SAMPLE <br /> MEASUREMENT I <br /> , <br /> PERMIT ; i <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />? <br /> MEASUREMENT f 1 {, <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />` L <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT f X <br /> PERMIT <br /> REQUIREMENT <br />NAMEIrITLE PRINCIPAL EXECUTIVE OFFICER I crrtif> under penalty of law that this document and all attachments were <br />re <br />arrd under m <br />dirmtitm o <br />wrvisio <br />nt <br />a <br />i <br />a <br />datn <br />with <br />st <br />d <br />i <br />ed TELEPHONE DATE <br /> p <br />p <br />y <br />f <br />ip <br />n <br />n <br />e <br />r <br />e <br />a y <br />ent <br />es <br />gn <br /> it) assure that ytudirird per ,nnel pnryxrl> gather and esaluate the information <br /> submitted. liwwd on mt inquire of the I-sn or Wr%ons %bn manage the system. <br /> nr those prnnns directly respmsihlr for gathering the infnrmatinn, the inbrmatinn <br />I I- <br /> submitt d is. to the twit of nit l trit-ledge and IM•lier. Intr. accurate:md cumldete. <br /> <br />I am aware that there are signira..I pen11- her -ah-Mrig false infnrmatinn. SIGN?TURE OF PRINCIPAL EXECUTIVE 1?) <br /> <br />TYPED OR PRINTED <br />including the p^sibility of nine and imprisonment f hat ..ing sit'h oat. <br />FICER OR AUTHORIZED AGENT AREA <br />OD NUMBER <br />YEAR <br />MO <br />DAY <br />ANU hXFLANAI IUN Ur ANT VIULAIIUNJ <br />an arracnmenrs nere) <br />NT: T? <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. 00Y4'2°9 This il, a 4-part: form.