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PERMITTEE NAMEIADDRESS din lm fl i a, day Name LeKaNen i(Diflerenu <br />NAME <br />ADDRESS 1J <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />MINOR <br />F - FINAL. <br />L^fT ? 1 iPiT T- i :t I , t\Irn ty r47I:.:F <br />ICK9N . <br />- X <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> C, <br /> PERMIT <br /> REQUIREMENT JN; <br /> SAMPLE , - <br /> MEASUREMENT <br /> <br />PERMIT REF'[lRT 0, 5 ?t e 'hi] <br /> REQUIREMENT jfjD A'':•'C7, DA I!-'`.' N Tl-' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ft} <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .'EFOF RF..`}r?s? r *p.# .'t•# #!! :? C)N'i _N '(:7n'lic, <br /> REQUIREMENT <br /> SAMPLE ?t .: . -4) <br /> MEASUREMENT <br /> PERMIT :r x 3t t3t r H:_ P r R - r c- -a iF' t 4th 4 Kt if ?t ;. > a w I C <br />l <br />? t:'_I 1L. <br /> REQUIREMENT _ r MONTH <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME TITLE PRINCIPAL EXECUTIVE OFFICER I card(} under penaly t.f law that this document and all amrchments were TELEPHONE <br />d DATE <br />prepared under my direction or supcr\iston to accord.•mce with a system designe <br />to assure that qualified personnel properly gather and csaluatc the information I /1 <br />/ - <br />. f- : , - r • %jLLPl 011 submitted. Based on my inquiry of the per4N1 or pcrSURe who manage the system, - / <br />,- - <br />• <br />or those persons directly responsible for gathering the information, the information - <br />";.70 72--"-!43-1;{ <br />ict <br />e: if?:.nt <br />, f <br /> <br />cr 01 05 <br />_ <br />submitted is, to the best c•(nnkno«Icdgc and belief. trig. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> am aware that there are significant penalises (or submitting false information. <br />! <br />l <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED , <br />at <br />on, <br />nicludm_l` the po-biluN all fide and Impasonment for kiw%Ing vio CODE <br />GUMMENTS AND EXPLANAI IUN Ut- ANT viULJAI1UNO (MCIUI VIK V <br />14 <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. <br />ucr c? <br />''ECIP EVENT 15UB JECT 1*0 BURDEN OF PPOOF <br />TO THE DIVIS3,10 i WITHIN /18 •'i?l!R ? <br />