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PERMITTEE NAME/ADDRESS (Include Facility Natne/Location if Different) <br />NAME .7 ?7 <br />ADDRESS , 'g <br />FACILITY 1 r . <br />LOCATION ` 5Lr > t <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DAR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM F; _ ,. TO r, <br /> <br />Form Approved. <br />OMB No. 2040-0004 Z <br />d <br />x ' <br />s":sal <br />NOTE: Read Instructions beforeMnpleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />?' . SAMPLE :.. ': •, G.: <br /> MEASUREMENT <br /> PERMIT <br />1. yW;e` T <;1!»' ,? r I REQUIREMENT ! 'r , . <br />.. •... t .., SAMPLE <br />vd;;y r:jp, MEASUREMENT <br /> PERMIT <br /> <br />I c3 ' <br />-5 REQUIREMENT 1 IV I "i - 'l, <br />s r ` SAMPLE ; .. ; ,... £:• >: t .' <br />y (`Ya N . .; MEASUREMENT <br /> PERMIT - is 2 ..> .. i ?_: <` •r?• ...?' . . <br />f s e., t;tc E_ p: REQUIREMENT t.y _ ? <br />±?!z i:?aV i > :: '. SAMPLE " " " _ E-a•. <br />a• ^ a <br /> MEASUREMENT <br />a • PERMIT g x z , .. 1. ..> <br /> . <br /># : <br />- <br />REQUIREMENT <br /> <br />I <br />- <br />j <br />_ - <br />71 SAMPLE <br /> <br />r+ <br />? <br /> MEASUREMENT <br />y .... , PERMIT <br />1° t _ c; .,•? S "' ' k!'. ._'U REQUIREMENT yx: i <br /> SAMPLE <br /> <br />71,' MEASUREMENT <br />- <br />} ` .. _ ., PERMIT -.! . *_ ._ :. ' a_;,t ..•`, a>` :k <br /> REQUIREMENT <br />iu t .. SAMPLE .., . ':.. i r • 1 <br /> MEASUREMENT <br />„7.. _ ._ k. PERMIT t. ... .. y; P, <br />,? M ¢ <br />f' o <br />` REQUIREMENT <br />y yy - s <br />it <br />f <br />y <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and an attachments were TELEPHONE DATE <br /> prepared under my direction or supervision in accordance with a system designed <br />p' j /?n <br /> <br />N `( <br />(&'t t <br />X to assure that qualified personnel properly gather and evaluate the information <br /> <br />erson or persons who manage the system <br />in <br />uir <br />of the <br />Ba <br />d on m <br />b <br />itt <br />d <br />, <br />• , <br />y <br />p <br />y <br />q <br />su <br />m <br />e <br />. <br />se <br />or those persons directly responsible for gathering the information, the information <br />?''" r •-) .!i !) submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECI,ITIVE t'"? ':,• •'" vt <br /> 1 am aware that there are significant penalties for submitting false information, <br />l <br />ti <br />k <br />i <br />i <br />d i <br />i <br />f OFFICER OR AUTHORIZE!D-WT EA NUMBER YEAR MO DAY <br />TYPED OR PRINTED a <br />ons. <br />now <br />o <br />sonment <br />or <br />ng v <br />mpr <br />including the possibility of tine an CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />Tl? <br />s '17kS?Y? 41 4-PL?Offfi. PAGE OF