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PERMRTEE NAL4VADDRESS (7ndrfr F«WryN-a?L«arar #fD(06nw) <br />NAME <br />ADDRESS r <br />'. OX <br />L JMA r., X35 <br />FACILITY '-"LANE CAii'v' :; •; iiiitE <br />LOCATION ;A 5 <br />- Trr? i , r? aIT• - <br />NATIONAL POLLUTANT DISCHAtOE ELIMINATION SYSTEM NPOES) <br />DISCHARGE MONITORING REPORT /DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO- I DAY YEAR MO DAY <br />FROM TO <br />MINOR <br />(SUE3R <br />F - Fl <br />G F iR ON I <br />Form Approved. <br />OMB No. 2040-0004 <br />4FT TESTING FOR 002A <br />GRFLD I <br />NOTE: Reed Instructions before completing tf?is form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. ICE°UENCr <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE 4 <br /> MEASUREMENT <br /> <br /> PERMIT REPORT ****a4 <br />y <br /> REQUIREMENT c? P <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ="# z .: if x sf# 1 C)Cf it lr S 3! ( _i. <br />Tl, REQUIREMENT 1N VALQE <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT =#iE;t> # # #? REPOF.T !(#If ::'i <br />r ##### T-RI GI.? <br />_ REQUIREMENT SING` _ <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT : k .. 100 #it#3t di it y rfLY 10IMP-. <br />- REQUIREMENT Mid VALUE- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT REPORT =, a• 11 a :: <br />U E L L' REQUIREMENT SIN SAMP <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT EPOP. ?I. <br /> REQUIREMENT [IN VA <br /> : <br /> SAMPLE <br />'HR' ; MEASUREMENT <br />PERMIT <br />REQUIREMENT 1> IVL:.`Y:r`f + Y <br />NAMErnnE PRINCIPAL EXECUTIVE OFFICER I rensty ° r Pena ry o lew Ihet IAN do IlWnl end ale sttachr amts wen TELEPHONE <br />prepared under my direcilon or sups r•Mon In aecordann with • system designed DATE <br />to assure that quaMBed personnel property rather end evaluate the Information <br />submitted. Bred at my inquiry or the person or persons who manage the system, <br />ar that persons directly respenslbM far gathering the Information, the Information <br />•-/ <br />v L? v <br />J : } <br />? Z <br />submitted Is. to the best of my knowadre and beIW, trove. a rsle. and complete. <br />7 <br />RE Of PRINCIPAL EXECUTIVE <br />I <br />T . <br />--• <br /> t am aware that there an slgrdffont pensities for submitting War Information, S <br />O A <br />U AREA . <br />PED OR PRINTED <br />Including the posdbNBty of Role and Imprbonment for knowing Avinuom <br />OFFICER OR AUTHORIZED AGENT <br />CODE NUMBER <br />YEAR <br />MO <br />DAY ! <br />COMMENTS AND EXPLANATION OF ANY VIVLA I IVII.1 irfs?srsnce M errecnrn@,nra neral <br />LOWL-ST % EFFLUENT AT WHICH STATISTICALLY SIGNTF DIFF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This IS a 4-part form PAGE OF