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PERMITTEE NAME/ADDRESS(lm"FwOyNa-WLa otia l(D(ff. t) <br />NAME <br />ADDRESS .. . <br />. _•. cUX 1++.1U <br />-1SAJ:• CI., tsl: <br />FACILITY J 5 I u i. \u a 1 it .i U j' .1 1 1 <br />LOCATION YK YALIZ)AL, <br />I :t:y Y.i1 1.1. 4 G <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /NPDESI <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER NSCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM _ TO _ <br />Form Approved <br />OMB No 2040-0004 <br />L LCAL C?ktl+ <br />NOTE: Reed Instructions bsftx• r.mmnletina this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, LI NCY SAMPLE <br /> r <br /> EX A-NALYS.S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />• _ <br />'- <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c E r U'.: r / ' <br /> REQUIREMENT '.• ;, n A '? .? u n ' (': t+',r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . E P G k. T <br />1 REQUIREMENT <br />ci;! <br />.. _ ,. i SAMPLE <br /> MEASUREMENT <br /> PERMIT v?Y0*,3:. <br />v REQUIREMENT J. r'. t a, i Y v <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT (:,ii <br />i <br />niY <br />V....? <br /> REQUIREMENT 7 ` n { <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />t -mly Y er pin. ty o Is. that trh document and .+i .11-hmenu we- <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />TELEPHONE <br /> <br />DATE <br />prrp.ed uwdlr my diKtlon owperrlston In .rord.n with . sysim dtslgned <br /> to more that qu.Nned personnel property ZW- and -Iwale the Information <br />rbmitted. Based on my inquir <br />of the <br />erson or <br />ersons wh <br />th <br /> y <br />p <br />p <br />o a anstr <br />e system. <br /> or thoss persons directly rsspo"sible for gathering the Inromnistion, the Information <br /> submitted Is, to the best of my knowledge ¦nd bellef, true, .revnle..nd complete. <br /> 1 a...am that them am dgniflc.nt pen.ttles for submitting f.ue Information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED , <br />tnciudinf the possibility of Mm and Imprisonment for knowing yfol.tl r OFFICER OR AUTHORIZED AGENT CAREA ODE NUMBER YEAR MO DAY <br />a.vmm?n t a nnv cnr v.r.rs ...,...., ,,... ....?....,,........r....r....., w..w.,...r.wc.w rr.r.r <br />i r 1, , CC I- t, <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This IS a 4--Pan form. PAGE OF