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PERMITTEE NAME/ADDRESSf7mj6&,Far&ryNowa/Laerriarr(/D(Q~) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTUA //NPOESJ <br />DISCHARGE MONITORING REPORT tDMRI <br />PERMIT NUMBER 04SCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read Inetrucdone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO <br /> <br />EX fREOUENCV <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER 1 sere"r "'Iff pen' 1r ° law that thb document and au .ttarhmenu .ere TELEPHONE DATE <br />prepared under m7 directlon or mper.ldon In accordance with • sfatem designed <br />to assure Mot qusAn d personnel property rather and eyafuate the Information <br />submfurd. Bawd on my inquiry or the person or, persons who mona`e the system, <br />or those persom directly raponslble for gathering the IMorenation, the Inforenallon - <br />- - -- , L_ sabmlttrd Is. to the bat or my It"wiedge and belief, Ime, a rste, and complete. <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />i <br /> i am aw.. that theft an 1t(rtlr <br />cant penaftra (or sobnittint rabe In(Orytssflon, <br />TYPED PRINTED Inriudlnr the paadDlllly of floe and Imprlsonmrnt for knowlnj .tol.uona OFFICER OR AUTHORIZED AGENT CODE NUMEIER YEAR MO DAY <br />COMMENTS ANO EXPLANATION OF ANY VIOLATIONS (Reference &N attachments here) <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This 15 a 4-pert form, PAGE OF