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PERMITTEE NAMEiADDRESS,inrlude Fanlin• Name'Lararion i/E)ijjen-nu NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS t? ? ?l Iw t Js:" <br />PERMIT NUMBER DISCHARGE NUMBER <br />FuC T MONITORING PERIOD <br />FACILITY <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />k <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. ! FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I Mkii-I <br /> <br /> SAMPLE <br /> MEASUREMENT <br />1105 PERMIT „ ## # #piiiFtE# a? ,? f'W ET H <br /> <br />_Fr <br />E <br />REQUIREMENT <br />r?P3 <br />,r SAMPLE <br /> MEASUREMENT <br /> PERMIT kF <br /> REQUIREMENT 'JvTi <br /> SAMPLE - <br /> <br />MEASUREMENT 1 <br />l? <br /> PERMIT ?.. • ,.;r. r•i[# #i=1 it is RCF•Ci ( -T I; <br /> REQUIREMENT :313Dr1 r?tit; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 4- ri 4, g R" 1Y?! y r. ;,. 10 <br />- <br /> REQUIREMENT <br /> SAMPLE ' 03) ?y :rte t #xt <br /> MEASUREMENT <br />J PERMIT r' i R"n©RT ###fi. =:r##'x ti c t.i'•i. _. D <br />_ REQUIREMENT Y v Lti.t - <br />r : SAMPLE 94, <br />:.- . <br /> MEASUREMENT <br /> PERMIT Ott r : REPORT r"i = I #i fir- <br />T-7?##?+? <br />s ? ?#k <br />t?? .-r <br />r •- ta; <br /> REQUIREMENT ; NST MP-.) <br />NAMETITLE PRINCIPAL EXECUTIVE OFFICER I ccnify under penalty of law that this document and all an.rchmenu were r TELEPHONE DATE <br />r <br />: <br />' <br />f prcpdred under my diromon or supervision in accordance with a system designed <br />erly gather and evaluate the ndornuaton <br />to avure that qualified pcronncl pro / <br />1 <br />t, <br />? <br />` <br />,- - I --- <br />' • p <br />inqutn of the person or persons who manage the system <br />bmitted <br />s <br />B <br />GSCd on m `/ <br />. <br />? <br />( , <br />u <br />. <br />, <br />y <br />the into nnatiun <br />oems directly re Twnstblc for g nhering the nformation <br />,•r those ? <br />? <br />v <br />J <br />?i <br />r <br /> , <br />p <br />d b <br />li <br />r <br />te <br />nd com <br />let <br />d i <br />k <br />d <br />d <br />f <br />i <br />b <br />h <br />b <br />f / <br />///- t <br /> ntr. accu <br />, a <br />p <br />e <br />s, to t <br />est o <br />now <br />e <br />ee an <br />e <br />e <br />, <br />a <br />su <br />mitte <br />e <br />my SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are significant penalties ibr submitting fal a information. <br />k <br />l <br />f <br />i OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />TYPED OR PRINTED now mg vo <br />at <br />oits. <br />ntcludm, the possubduty of <br />ine and impnsonmeat for <br />COMMENTS AND EXPLANAIIUN Ur ANT vIVL AI IUNZ Irreverence an dudcnrnents nerel <br />::CIP EVENT SUBJECT TO BURDEN OF PROOF PEGUIREMENTS If-1 <br />TO THE DIVISION WITHIN aS HOUR'3. <br />EPA Form 3320-1 (Rev. 199) Previous editions may be used. 00561, _, x(1i- 049 4-part;fonn.