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PERMITTEE NAME/ADDRESSp+eiMF.rierx?n/[or.nen(/DIQi..nU <br />NAME <br />ADDRESS <br />11 k_ N <br />FACILITY <br />LOCATION <br />lc R6, <br />NATIONAL POLLUTANT OISCHMGE ELIMINATION SYSTUA INPOES/ <br />DISCHARGE MONITORING REPORT (O R) <br />PERMIT NUMBER k-SC--MG[ NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Reed Inetruetlorw before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br />EX FREOLI NCY SAMPLE <br /> ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/T1TLE PRINCIPAL EXECUTIVE OFFICER i cernq a r pen. y *(law that this document and all attachments were TELEPHONE DATE <br />prepared under my direction or supervtslon in accordance with a system defi=ned <br />to anum that quallnd pr? nel pro"Ay gather and evaluate the Inroemellon <br />' subrrrltad. Based on my Inquiry of the person or pers ms who -re the fyelem <br />or those penere directly mponsibk for gathering the Inforsrutlow, the Information <br />submllted K to the bnt of my knowledge and beW, true, accurate. and c'otnpkle. <br />- I <br />th <br />t IA <br />l <br />nlfl <br />m <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />l <br />f <br />b <br />i <br />I <br />i <br /> am aware <br />en are s <br />g <br />ca <br />a <br />pena <br />m <br />tnng Paler <br />nfornunen, <br />t <br />es <br />or w AREA <br />TYPED OR PRINTED Indudint the possibility of floe and ImpAwornent for knowing vldanotes, OFFICER OR AUTHORIZED AGENT CODE NVMBER PEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference *# athchment: here) <br />???11'. r•Il-iv: I... •yr\LF1 :]1._ ._. ,i.. .,. +:. i.. l:•.' iii: ._.-. ?-i.l 'ds t_, ?.?'_. . '..j:\"7 '- J <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used This is a 4-Part