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PERMITTEE NAME/ADDRESS pwob4Fo-Ooy Ne WLorortoa (/D(Or-,) <br />NAME <br />ADDRESS <br />. box :.;.,t) <br />?ADc l; t: c <br />FACILITY jjDr, t:?iiir t ?C.OTtI ("iNi <br />LocATxxr PALI:?Au <br />CC t <br />10 N 1. . xtr.r.ti ,,. V_n_ <br />Form Approved <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) OMB No 2040-0004 <br />DISCHARGE MONITORING REPORT WMR) <br />PERMIT NUMBER DISCHARGE NUMBER _ A k l? <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO _ -->,/1 <br />NOTE: Read Instruction befor ti tomlating this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCr SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> L 1, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br />" z' <br /> <br />= r C r T <br />C <br />it / <br />h A L <br /> REQUIREMENT <br /> LJ I?r `k i, :Ch )i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT tr % U U 0 <br />y r <br /> REQUIREMENT . <br /> ( r, <br />r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 1i't,kQ1: ,ciUn: .N, <br /> REQUIREMENT <br />` <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT % <br />_t<iiVl:,uA <br />REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER ' fe^"' " •r penalty ° 1i"'^" `^`' d xu'It. ""d all •n.rnmr"? wrrc <br />TELEPHONE <br />DATE <br />prepared under my dlrectlon or aperHsion I. atcordan,c< with • sysim designed <br /> to aeum that qu.fln d penonnei proprrly gather and e•alu alt the Informalbn <br /> abmttted. Stated on me, Inquiry or the person « person who manage, the system, <br /> or those pers.:, directly respor,sibk roe, gatherin <br />the Informatlos <br />th <br />l <br />ror <br />lM " <br /> g <br />, <br />e <br />n <br />ms <br />n <br /> abmltred b, to the best of me knowledge and belief, trve, accurate, and mmpletr. <br /> 1 am .ware that there are significant penallln for submitting Wee Inrormatlon SlaNATURE OF PRINCIPAL EXECUTIVE ' - ' <br /> <br />TYPED OR PRINTED . <br />Inciuding the possibility of fine and Imprisonment for knowing .lolatlorrs. <br />OFFICER OR AUTHORIZED AGENT ARE <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />I.VMMCiY 1 J AMU C^rL mm r nvn v. •+... .... ?... ,v.w nnwrwf -rue, wrr wuwe.rrrnnwrr,J rrwcap <br />Ivns"s "'tF-C'lP iV:,teI CC CI,.:, 3IJhJEC1 IU 6LECEN CF krCLF <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan form.