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PERMRTEE NAMEIADDRESSpm&ks rwyN..?L?oti-(fDlpi..u) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R( <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 />NOTE: Read irwtrvctions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />E FREOuENcY <br />of SAMPLE <br /> X ANALYSIS TYPE <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 /> <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 />I eertrty u r pen/ ty a /w that Ub doc• mrnt and /N attachments wen T <br />ELEPHONE <br />NAME/T1TLE PRINCIPAL EXECUTIVE OFFICER <br />I <br />DATE <br />Prep/red ruder my elf-lion or /up.. 1 <br />on In accordance with ¦ system earned <br />to asun that qushfkd personnel property ether and evaluate the Information <br />. 1s"Ilyd <br />Bred on m <br />In <br />uir <br />of the <br />tnom w <br />wh <br />r <br />e th <br />l <br />. <br />y <br />q <br />y <br />P <br />pe <br />sons <br />o mang <br />e /ys <br />rm, <br />l <br />or those Presents direct <br />y responsible for gathering the Information, the Inrormalbn <br />- ,- submlttrd is. to the bat of my knowledge and besef, true. accurate. and complete. <br />I am 1hol then an significant Penalties for.rbmltdn <br />raise information <br />SIGNATURE OF PRINCIrAL EXECUTIVE - <br /> g <br />. <br />I <br />TYPED OR PRINTED nciudlnj be possibility of floe and Imprisonment for knowint W.doms OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Referents aM attachments here) <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part. Bonn PAGE OF