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PERMITTEE NAMEMDDRESSpn?iri e+hryNw?Locar.nUla?,..nq <br />NAME <br />ADDRESS <br />• ,. }iGX 14.14 <br />cc <br />FACILITY ., I D£ ?:: U T r 11 <br />LOCATION PAL 1 CL <br />Form Approved <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /INPDESI OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT WMR/ <br />PERMIT NUMBER DISCHARGE Nwam _ F I b A 1 <br />MONITORING PERIOD j I. J h A C C h I V r h <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Reed Instructions before eorrlpieting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, NCY <br />FREG SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />I <br /> REQUIREMENT <br /> M. - <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 />v <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I "rtu. under penally o law that this document and all aftachments were <br />TELEPHONE <br />DATE <br /> prepared under my dirrctlon or wpenlfon in accordance wllh ¦ system dtsdgned <br />_ to aare that qualffl d perwnnei properly gather and evaluate the Infermatbn <br /> snhmllled. Based on my Inquiry or the It- tw pereom who manage the sperm, <br /> or thesis persons directly responsible for gathering the Informa[lon, the Informallen <br /> submitted is, to the hest of my knowledge and beller, [roe, accurate, and complete. <br /> "I" " that there are slgNncant penalties For ssbmlttl^g raker Info m slon, SIONATVRE OF PRINCWAL EXECUTWE ? <br />TYPED OR PRINTED Irvcsuding the padblYly of Awe and Imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />CM I J AFVL4 CnrLnnn n rvr. v. n... ....... <br />ietc':A'1A1i0r5 ++NEt: 1(rYh,214JR ei+EC1ra EVE,1*1 CCLLRS, SUuJEL1 IC Pl t-LIN CE FFF.M <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form.