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PERMITTEE NAMEJADDRESS gsusiu r FerwyN..?terr/an uD(&-') <br />NAME <br />ADDRESS <br />FACILRY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM (NPDES/ <br />DISCHARGE MONITORING REPORT WMR) <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 Inetructione before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />Y <br /> ANALYSIS T <br />PE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <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 />i mmay under pena ty *(law that this dorvmrns and all attachments were <br />TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br /> <br />DATE <br />pmpartd under my dimrtion or tupe hi <br />r+on Inaccordance with ¦ %yssem desltned <br />to aaum that qudlntd personnel property gather and evaluate she Inrorenatlon <br />submitted. Based en my Inquiry of the person a persons who manage the s <br />stem <br />. <br />y <br />W those per"" dlreclly -porelbk for gathering the Intornutlow, the Int-tion <br />submitted is, to the best M my knowledge and belle!. Imes accurate, and comIskit. <br />I am swans that then: are st <br />nintant <br />tnaln <br />ror <br />SIGNATURE OF PRINCMAL EXECUTNE <br />bmitd <br />f <br />Inro <br />tl <br />ls <br /> g <br />p <br />e <br />sa <br />ng <br />a <br />e <br />nea <br />en. AAEA <br />TYPED OR PRINTED Including !ht posaibl9ly or one and Imprfsonmrni for knowing rW.Uors OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS [Reference eM attachments here) <br />r• <br />f T <br />t <br />r}=^ tY <br />. <br />] <br />u <br />s <br /> ; l n i ?rFF! <br />T 1 <br />A <br />rl <br />; <br />F <br />L,ji <br />i <br />AT P1 fiF <br />I <br />I_ <br /> <br /> <br />EPA Form 3320-1 (Rev 3:'99) Previous editions may be used This is a 4-part form, PAGE OF