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PERMITTEE NAME/ADDFtESS pn.66 Frrot Xo*?L? ,wi n tfDeeewv) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINAnoN SYSTEM /NPOES) <br />DISCHARGE MONITORING REPORT IDMR) <br />PERMIT NUMBER DISCHARGE NLIMeER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read kwbucdonig before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />T <br /> ANALYSIS YPE <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMElTiTLE PRINCIPAL EXECUTIVE OFFlCER I cer"y under pen. q ° .w that this document and all .ttachmenu were TELEPHONE DATE <br />Prepared under my direction or mpreAulon In aaeordanre with • eystern designed <br />t° assure that quatifled personnel property gather and evaluate the Information <br />. wtbmltied. Based on my inquiry of the person or person who manage the system, <br />or those peraon directly reaponslbk for gathering the information. the Information <br />wbmltted h, to the beat of my knowledge and beW, true, accurate. and complete. <br />I <br />m <br />.. <br />t th <br />n <br />l <br />in <br />t <br />n <br />1th <br />b <br />ltu <br />l <br />f <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />th <br />f <br />W <br /> a <br />a <br />" <br />a <br />en a <br />gn <br />can <br />pe <br />. <br />s <br />or wt <br />m <br />s <br />ng <br />ar <br />n <br />ornrtion, REA <br />TYPED OR PRINTED Inrfudlng the possibility of nn and Imprisonment for knowing Ool.uotts OFFICER OR AUTHORIZED AGENT DE NUWAKR <br />CO YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (RlflrenC* *M •ffachmenfs here) <br />EPA Form 3320-1 (Rev 3199) Previous editions may he used This is a 4-pan form.