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PERMITTEE NAMEiADDRESS.Du iii i, I e ti;r, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO - <br />NOTE: Read Instrurtinnc hefnre <br />Farm Approved. <br />OMB No. 2040-0004 <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ., k z <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME:/TITLE PRINCIPAL EXECUTIVE OFFICER ,crttf% urtdcr pcna;t'.. Low that this dexaanent and all attachments were TELEPHONE DATE <br /> prepared under m} drre,tiun or supercLmon in accordance with a system designed <br /> to assure that qualified persunncl properly gather and c%;duate the information <br />1 <br /> subinine l- Based on my inquiry of the person or pcrcons who manage the system, HA,,, <br /> or those per%ons directly resr ntsible tin gathering the information. the information <br />. <br />?7 <br /> submitted t, to the hest of my knowledge and be:ltef, true. accurate, and complete. <br />I <br />wn aw <br />;h <br />t th <br />fi <br />l <br />f <br />b SIGNATURE OF PRINCIPAL EXECUTIVE . <br />TYPED OR PRINTED , <br />are <br />a <br />ere are si?mr <br />cant pena <br />tie, <br />or su <br />rnmtng fad c tnfomuatort. <br />utclodine the Kstbihty of tine and tm monment for knoem, violations <br />lx p OFFICER OR AUTHORIZED AGENT AREA <br />' NUMBER <br />YEAR <br />MO <br />DAY <br />?f?u.•r.a? •ur? runt A\I A-L' Ar A.IV CODE <br />HEP: <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />TAT I 6 l I C l',; t Y 5I Q1 <br />This i&u. 4=part fonn. PAGE