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PERMr TEE NAME/ADDRESS p-huh,F.eWry NaaaWL-lonIIDOW-w) <br />NAME <br />ADDRESS <br />c3- 1: <br />FACILITY <br />LOCATION _KEN <br />NATIONAL POLLUTANT OISCHAROE EUIAINAT10N SYSTEM ((NPDES/ <br />DISCHARGE MONITORING REPORT (DMR/ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY Y AR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040.0004 <br />NOTE: Reed k+structlorw bsfors complstft this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br />J <br /> REQUIREMENT r• <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 />NAME/TiTLE PRINCIPAL EXECUTIVE OFFlCER ' c.nn'y " of penalty ° I¦. that mk doevment end all.tlschments were TELEPHONE DATE <br />prepared under my dlr lion a mia",ts/on In accordance with • system designed <br />to assure that qualified personne; property father and evaluate the Information <br />. s"bmilled. Based on my Inquiry or the prrmn or persona who manage the ",am <br />or those persons dlrectly rv,;F mlIbk for gathering the Information, the Inform¦•lon <br />kn <br />b <br />t <br />f m <br />.l <br />d <br />li <br />t <br />h <br />d b <br />f <br />d <br />l <br />o <br />y <br />o <br />e <br />ge an <br />_ mbmtlled 11, to t <br />e <br />es <br />e <br />e <br />, am., accura <br />e, an <br />comp <br />ete- <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />dn <br />l <br />I <br />`'- <br /> 1 .m .w.n an mere .re a <br />gn <br />oat penaltle r°r a"bnnnnnE rate <br />nrornrlwn, <br />TYPED OR PRINTED lnckdinglhepossibility of fine end Imp rhanmentfor kn,owlnt.lw¦uona, OFFICER OR AUTHORIZED AGENT CODA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference oM o"achmonts hors/ <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This is 8 4-parl form. PAGE