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PERMITTEE NAME)ADDRESS,7.&&Frft Kaaawj.r.trow(/D(aant) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLVTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT ID R/ <br />PERMIT NUMBER DISCHARGE Nt1MEEIt <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read kwtnfcdone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOLI NCY SAMPLE <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 /> PER MIT <br />I REQUIREMENT <br />NAMEfnnE PRINCIPAL EXECUTTVE OFFICER I rertlty a r pens ty o law that thb dtlcament and alt attachments wrre TELEPHONE <br /> <br />pnparrd ander my dlrectlon or wpen1 - In actordann with • system designed DATE <br /> to Wan that gaaMned personnel property gather and esataatt the Infors non <br /> fobnitied. Eased on my I rgalry or the person a persons who manage the sy/tem, <br /> or thou persons directly -pondble for gatkm.g the Inrtxmatlnn, the InrormaUon <br />bn <br />11 <br />d <br />t <br /> w <br />11 <br />e <br />K to <br />he best or my knowledge and b*IW. true, accurate, and cpnplett. <br />- I am aware that then are slgnifkant penaltles for mlinaltring fshe InfornotSon, SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED InHading the poalbillty 0 one and Imprtsonenent for knowing violations. OFFICER OR AUTHORIZED AGENT NUMBER <br />C YEAR MO DAY <br />at • Ttrl\I Al' • \IV t/1111 • TIr1\1w ODE <br />a Wmmusr.a rs l.v rr......- _. ..... .... ?.......... In.r.. area.. w..n a,nnr?srw nwrari <br />EPA Form 3320-1 (Rev 3)99) Previous editions may be used PAGE OF <br />Is is a 4-pan form.