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PERMITTEE NAWADDRESS (7neb6 F?rtlrry/fwn?Leragee (/D(?e.vnr) NATIONAL POLLUTANT OISCHARGE ELIMINATION SYSTEM (NPDESJ Form Approved <br />NAME DISCHARGE MONITORING REPORT (DMR) OMB No 2040-0004 <br />ADDRESS <br />PERMIT NUMBER OISCHAROE NUMBER <br />C0 <br />FACILITY MIN' MONITORING PERIOD <br />LOCATION R PAL-ISADE YEAR MO DAY YEAR MO DAY <br />c_ FROM TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br />` SAMPLE <br />- MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT a`. <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT -1' rR A'G {IF'"1'r•. ;'Ir?ii <br /> x. - <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT - . :. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ' "Miy a r penalty 0 Law that this decvmrnt end all ellarhments were <br />TELEPHONE <br />DATE <br />prepared under my direction or fupenlelon In ateordenn .Ith • fyrtrm doltned <br />•?{ ,, to soya that qualified personnel properly gather and e•eluete the Infnrmatlon <br />terbmitted. Stated on my inquiry o1 the person or Persons who menage the ¦yriem, - .... <br />• <br />? <br />. <br />.. <br />. <br />. <br />. <br />_ <br />- or those persom directly resporedble for gathering the Information, the Information -- , - i <br />submitted Is, to the best of my knowledtc and belief, troy, ertntrate, and complete. +-- <br />I am aware that then: art dtnifteant penaltla for mbmlttint false Information, SIGNATURE OF PRINCIPAL EXECUTNE <br />TYPED OR PRINTED trmeuding the poalblNte of fine and Imprhonment for knowing .W,tJoa& OFFICER OR AUTHORIZED AGEKT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference aN arrachmonfa here/ <br />TOTAL SUSPENDED SOLIDS CTSS), TOTAL <br />EPA Form 3320-1 (Rev 31") Previous editions may be used " 082