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PERMITTEE NAME/ADDRESSQaft6kF.rWryNaw fLocaion(fDlQrernq <br />NAME <br />ADDRESS _ _- <br />CUX 14 JO <br />CU b154 <br />FACILITY ;; _> I U h & L; :z ,i t1 t a I; u T ri FI I ?+ E <br />LOCATION A h a' A L I S A b :. C,:; t; : s <br />.1.'.Iih 1.. K 11.t,. L k _ V . L. <br />Form Approved <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (INPDES/ OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER - FIN A L C ? = <br />MONITORING PERIOD C F. k k <br />YEAR MO DAY YEAR MO DAY _ <br />FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, SAMPLE <br /> 7 <br /> EX -AL TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT fa . . , . U <br /> REQUIREMENT <br /> r t <br />i1AX <br />r, L <br /> SAMPLE <br /> MEASUREMENT <br />1 PERMIT - / <br /> <br />, REQUIREMENT <br />• <br />_ .. _ : ,.. SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />LAI LY <br />.;.T: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t <br /> REQUIREMENT <br />u 1. <br />i ? <br />7 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _FC:.. it.FCR1" r;IY Ih I <br />h: <br /> REQUIREMENT A ; :1 i L Y 1 <br />;•_ SAMPLE <br /> MEASUREMENT <br />! PERMIT -? ca?'i hilGr."i ft ErCit l <br />REQUIREMENT ?. ! t1 F y r i. T M "I ?I y <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I cerirly " ee pen. ty " 1- that thls d-menl and all alnchments were - <br />TELEPHONE <br />d <br />i <br />i <br />DATE <br />prepare <br />ender my d <br />rect <br />on or wper+islon In accordance with . system designed <br />, <br />to .setae that quatined personnel properly gather and evaluate the Inrormallon <br />- aabm111M. Bred on mr Inquiry, of the person or penoro who mana <br />e the s <br />stem <br />g <br />y <br />, <br />or thou persore directly mpordble for gathering the Informatton <br />the Information <br />• <br />b <br />lll <br />t <br />th <br />b <br />t <br />f <br />tn <br />i <br />d 1 <br />d <br />. eu <br />e <br />% <br />e <br />o <br />my <br />ow <br />m <br />o <br />es <br />e <br />ge and btlW, Ime, arc urate• and c ptete. - - - I <br />I ¦m "I" that the- are significant penalties for aubmllting rape Inrormation <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />Including the possibility of fine and imprisonment for knowing `iolattorK OFFICER OR AUTHORIZED AGENT CAREA <br />ODE NUMESER <br />YEAR <br />MO <br />OAY <br />GUMMCN I J ANU CArLAN/11 tvn yr nr. I .rvt.n r Iw"Q Inarrirrernct/ tan atrnenmmw neref <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. TINS IS a 4-pan fonn. PAGE OF