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PERMITTEE NAME/ADDRESS (Include Facility Name/Location i(Different) <br />NAME , -- <br />ADDRESS <br />ct; <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />`DISCHARGE MONITORING REPORT (DMR) ! , h ;( OMB No. 2040 0004 <br />PERMIT NUMBER DISCHARGE NUMBER 7!V+' t' ` iv a <br />MONITORING PERIOD r% <br />YEAR MO DAY YEAR MO DAY <br />FROM F . TO u: = t_ NO 1. _ "C71 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE , .. . - .. :i y :.., <br />;:;r`°: _; .l•':f°.. ': MEASUREMENT <br /> <br />_.. :? <br />PERMIT <br />f ?r ?; : <br />,. <br />x r c# <br />F >t .r 3 • i <br />" <br />F <br />F -, 77 <br />?.: <br />REQUIREMENT ?• r r Y.? c ?.lr , r Jl' _ lel Orl-: I F <br />_ . _ . .. " , SAMPLE 'A:• T : =t .. .. . <br />?i~ MEASUREMENT <br /> <br />_. .. _ t .. <br />PERMIT <br />, .u..=.. :. <br />*7 r?: #•;x• ., <br />t_ <br />l.? <br />' x <br />k:r <br />T r.7 <br />$ <br />,A"i -l._ <br />L <br /> <br />REQUIREMENT <br />?. .<. i.,?. <br />t ?a.v <br />s 1°"A A ? - <br />i. ?e ,It i _. ?•i f': <br />i..l'L-1:,?._. <br />y <br />( <br />y <br />(Fi S..l3 `I 4 t'1 <br />,• SAMPLE <br /> MEASUREMENT <br /> <br />_. _ . _. ? <br />PERMIT <br />? ?L f <br /> <br />• t r .:ji F- ...._ii U? 'F.E it-.E <br />.7° i ?_._' _ . tea`; • r V.-•_._ <br /> <br />REQUIREMENT <br />(iX n,? <br />i`t't0.ly Tf-jf <br /> SAMPLE <br /> MEASUREMENT <br />tsti- ?' PERMIT <br /> REQUIREMENTS <br />Ll f'Y Y t t ?j Y. <br />IL I <a 1 <br />? i\J! ? ,i/5.1 .yam <br />F14 <br /> SAMPLE <br />I"f-1'°•;°_ :-°.:,={: % Jz' (?:`' .. MEASUREMENT <br />r:. [ : -. '-• ? PERMIT • -A 4 _ .' <br /> REQUIREMENT u ; ;la U.'r'° hi ;As`-,1 `._ Pii'1! <br />.. _ SAMPLE <br />cfr_tP..;;- MEASUREMENT <br />- , <br />PERMIT ,i. -?: a!•?I- r ?• -x :.. ,.; ?• -# ::* ::•'?,? ?'r ? r -'r it• : r. : i :. r .. t.! `:: . ( ? '?, ._, ;W', r' i .. <br /> REQUIREMENT <br />- <br /> <br />t ., <br /> <br />SAMPLE <br />rT <br /> MEASUREMENT <br /> PERMIT -q-1 "'s_ l° .. <br />'L-).$z..r-t : _ REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br />t, <br />?7 F FOAN E•t?'-7 prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the information <br />l VtV. / <br />C fff t <br />submitted. Based on my inquiry of the person or persons who manage the system, <br /> the information <br />or those persons directly responsible for gathering the information <br />Go , <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />f <br />l <br />i <br />l <br />i <br />f <br />i <br />i <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE LP <br />G f <br />l/ <br />1 <br />?- f <br /> <br />TYPED OR PRINTED se <br />ormat <br />on, <br />t <br />es <br />or subm <br />tt <br />ng <br />a <br />n <br />I am aware that there are significant pena <br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT 'AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATIUN UP ANY VIULAI IUNS (Hererence all arracnments nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 0001," _ " 0. 1 5IV9" 4+.pHXI't form. PAGE ? OF