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PERMITTEE NAME/ADDRESS (Include Facility flame/location if &fJerent) <br />NAME <br />ADDRESS - - - <br />163° <br />FACILITY <br />LOCATION 639 <br />FR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 />;.I i <br />F <br />U (JiG TU TFiI:s/t Ith?St?', (.FtLEI',- <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT J <br />I i <br />1 / <br />v? <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT r I !- <br /> PERMIT <br /> REQUIREMENT <br /> <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 <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif, under penulry ttf law that this d-ument and all atbahmrnh wen I TELEPHONE DATE <br /> <br /> <br />U?11TUS ?}OIIC? prepared under nit dirmtiun or -l- ision in accordance with n s? stem designed <br />Ir-einrl r"Pert. gather and esaluute the information <br />to assure that t!uahried <br />' <br />, <br />I?rO???l f m. <br />wbmiued. Bused un inyuin of the prrst m .r perwms who manut;r the -tern. <br />of <br />or thtst• prnom directh respomible for gathering the information, the inrornwtion <br />. <br /> <br />70 276-5209 -I ittrd is, at the Ira of mm knowledge and belief, true. accurate, and complete. <br />4 <br />SIGNA URE OF PRINCIPAL EXECUTIVE L/ <br />TYPED OR PRINTED nira unt penalties for submitting fakir information. <br />I am ..are that there am <br />including the latssibitin of fine and imprisonment For ktmwing ,iodations. OF CER OR AUTHORIZED AGENT AREREA NUMBER YEAR MO DAY <br />I:VMMtNI, ANU CArt..041-4Mllvn yr Mtge vtvt-MIItO"Ci dmmivttvnt,c an anaonntanw rtcta/ <br />. 'RED TO REQUEST A REASONABLE POTENTIAL ANALYSIS BE <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. ?'' T%% iS a 4-pare- orm.