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PERMITTEE NAME/ADDRESS 171--6&Fadk1y Nww?Loew1*v ifD(dWwn) <br />NAME <br />ADDRESS <br />»Ox 14jU <br />-IShn6 CL dlbzl <br />FACILITY U5IL? hURIN G :iUU•Th '!li`t' <br />LocArloN •-N PALi?ADZ CG bltlE <br />I COm 1 _ w I t . : r. C - 1) - <br />Form Approved. <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM /INPOES! OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT /DMR1 <br />PERMIT NUMBER DISCHARGE NUMSEA S 1 <br />- F . ?At Ml:: <br />N <br />MONITORING PERIOD K C A L C F E L K <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Irmtructiorw before a ihpleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. U <br />NCY <br />FREO SAMPLE <br /> O <br />F <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- <br />t . _ . <br /> REQUIREMENT <br /> <br />r SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br />r SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />r SAMPLE <br /> MEASUREMENT <br />1 <br /> PERMIT <br />` <br /> REQUIREMENT <br /> ti <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> iT <br /> <br />- SAMPLE <br />? MEASUREMENT <br /> <br /> PERMIT r• ) rt,t Y <? •'? itLY 1: .At <br /> REQUIREMENT 7 <br />r <br />I <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT , .. .• > : . n v _ <br />REQUIREMENT <br />- <br />AME/T1nE PRINCIPAL EXECUTIVE OFFICER l nntty under penalty o h. that thh dorument and all et1whmentr wen <br />TELEPHONE DATE <br />Prepared under my direrlbn w •uprr.llon In aecordantt with • system deigned <br />to man that qualified personnel properly gather and ee.luate the Information <br />submitted. Based on my Inqulry of the person w persons who manage the system, <br />w (hose persons dlrertly responsible, for galhering the Informallon <br />the lnro lion ) I <br />r <br />, <br />4 <br />submitted Is, to the best or my knowledge and beMer, true, atcumle. and complete. r <br />`- <br />- <br />1 am .wan that there are slgnll}ran( pmaltles For submitting tale tnform.flon• SIGNATURE OF PRINCIPAL EXECUTIVE r <br /> <br />TYPED OR PRINTED <br />Including the possibility of fine and Imprisonment for knowing Holatlorts. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />C:VMMCIq l J /'1 r'dV Cnr Lnnn r rvr• v. n.e . . ?v?r• ?vn? l-wr - awe an e•r?nrnwn es nwr ?/ <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This IS a 3-part form. PAGE