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Pr HM; ?EE NAME,ADDRESS <br />NAME <br />ADDRESS REEF <br />40 ,OW1 E <br />NIA '?I, C1 c:, <br />FACILITY ROR CREEK i_ L;AF`l't 1 <br />LOCATION -4 I A r_ r; g 3 <br />'.IES T. COOF"ER r PR f"9i I r)FNT <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER FINAL DEWT <br />MONITORING PERIOD POND * -P Ii GUNK T SN <br />YEAR MO DAY YEAR MO DAY <br />FROM TO _ X <br />NATF• Raarl Inctrurtinnn hafnra rmmniatina this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT S 3Ft#st## F REPORT Ti?LY 'R <br /> REQUIREMENT DAILY <br /> SAMPLE A, ' <br />- MEASUREMENT <br /> PERMIT R .>'opY 'r - ,=_? it##>rn# atitxil i x#;?### k{: x - KL ! AL <br /> REQUIREMENT INST ht ar a <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif} under peMir• of low that thus document and all attachments were TELEPHONE DATE <br /> prepwril under my direction or wpzrvision in accordance with a system citstgned <br /> <br />- <br />l t.• assure that qualified personnel properly gather and evaluate the infbrnwttun <br />submit tl. Based on m} inquiry of the person ur pouts who rt mm c the system <br /> <br />' . <br />or those persons dtrcctly responsible for gathering the information. the iufurmauon <br />?• I 4 <br />f ;11 I z/ - j :3`l6 <br />•• <br />-Z <br />j d 1J submitted is <br />to the beet of my knowludgc and helief <br />true <br />accurate <br />and com <br />lete I <br /> . <br />, <br />, <br />, <br />p <br />I <br />i <br />fl <br />l NATURE OF PRIN PAL EXECUTIVE <br /> <br />TYPED OR PRINTED int their are sign <br />ficant pena <br />ise; t,,r subntitmg false inl-rmat on. <br />am aware <br />including the Ixtssibdit% of fine and tmpm-nnient for ktnowmg violati ns. OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />oar. r.+'v.v v.rrrnMr Ivry yr frr? r •rv?++r rvrw Incf CrC "Call arraGtllllGlttJ flat Cj <br />-HR PRE <br />EPA Form 3320.1 (Rev. 3199) Previous editions may be used. PAGE <br />L -: n8 This is:_a 4-part form. -,