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PERMITTEE NAME/ADDRESS17--&*ir•WryNwWLe ante (fD(fl .w) <br />NAME <br />ADDRESS ` L S <br />•. duX lu ?v <br />.1sAD l;U l71?s <br />FACILITY <br />LOCATION u t_ <br />VALI-SADF <br />Form Approved <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTDA (NPDESI OMB No 2040-0004 <br />DISCHARGE MONITORING REPORT (DMRI <br />Lu) <br />PERMIT NUMBER DISCHAAGE HUMS EII _ F <br />MONITORING PERIOD C CCLCnALC h.L V <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Ir>.tructlons bsforo'eo4letIn9 this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />. <br />NO <br />EX FREOUENcY <br /> <br />OF <br />SAMPLE <br /> <br />Y <br /> ANALYSIS T <br />PE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />r ?? r.2 Y <br />1 , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />I "Mly under penalty .(Is .. IA?1 Ihfs document and all .11-liments were <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />TELEPHONE <br />DATE <br />prepared under my direction or supervision In accordance with • system designed <br />_ to aware that qualified personnel property j.ther and evaluate the Inrormatln <br />submitted. Bred on my Inquiry or the person or persons who manage the system, <br />- or those persons directly responsible for gathering the Infonseuillon, the Information <br />submitted Is. to the best or my knowledge and beW, Ime, a -irvic and mmplelt. -- <br />I am aware that thus are sl <br />ntnr¦nt penalties for subriiltin <br />rata tnrnrmatlon <br />SIGNATURE OF PRINCWAL EXECUTIVE <br /> g <br />g <br />, AREA <br />TYPED OR PRINTED induding the possibility or line and Imprisonment for knowing l As0onf, OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANA I lvn yr nn T vfvl-rt t Neva rrfererenc• an •rracnments noel <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-pan form. PAGE OF