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Form Approved <br />PERMITTEE NAME/ADDRESS (Ym&kFadbryNa.r'L ere- (/D(06eaet) NATIONAL POLLUTANT DISCHAROE ELIMINATION SYSTEM ((NPDESI OMB No. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />n lV X i ti PERMIT NUMBER DISCHAnaE NuaBER - t S A A L 11 c !+ <br />. i <br />C0.f LA Uh MONITORING PERIOD <br />LOCATION C L C: r. l: C :+ i E h <br />: 0a I U!., fe I, ... _ YEAR MO DAY YEAR MO DAY _ <br />FROM TO <br />r Y Ai1 R i : - NOTE: Read Instructions Wows completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />U'NCY <br />FREO <br />SAMPLE <br /> I>< O <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />" <br /> V A <br /> <br />r SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />/ <br /> REQUIREMENT <br /> LJL '• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t v: k' ... G r 7 i• / F <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />l• <br />/ J v <br /> REQUIREMENT r <br /> I <br /> SAMPLE <br />I <br /> MEASUREMENT <br /> PERMIT t{ <br /> REQUIREMENT <br /> <br />r SAMPLE <br />L tt G A'1 .1 MEASUREMENT <br /> PERMIT r. z ., :.. t L e C h T a. <br /> REQUIREMENT L L Y Mx <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT F( t,, •. u* ?LYV1 iuti <br />REQUIREMENT <br />NAME/ TITLE PRINCIPAL EXECUTIVE OFFICER ' "rt'Ty ° `r p`""y ° '"" that tnh dxumenT and .11 "IKhmmb were <br />TELEPHONE <br />re <br />ar <br />d o <br />f <br />d <br />i <br />l <br />l <br />I <br />DATE <br />p <br />p <br />e <br />rer t <br />on or super. <br />r <br />er me d <br />r <br />on <br />n accordann with . System designed <br />le aware that qualined personnel Property gather and eraluate The Info Ilon <br />submitted. Bred on me I"utry *(the person or pereom who manage the System, <br />or those prnorn directly repo"We for gathering the Inforrratton. the Information <br />submitted K to the bnl of my knowledge and belief, true, a rale, and mrnpkte. - <br />I am aware that there are Significant pmaltin for submhting rate inro-tion <br />SIGNATURE OF PRINCIPAL EXECUTIVE , <br />TYPED OR PRINTED . <br />Including the possibility of fine and Imprisonment for knn.lnir loiatJom OFFICER OR AUTHORIZED AGENT CODE NUMEIER YEAR MO DAY <br />COMMENTS AND LAVLANA I IVN yr Arm T V IVLPk I IVrla frferoronce, an arracnmenrs nsrs/ <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This 15 a 4-part fonn. PAGE OF