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PERMITTEE NAME/ADDRESS (7seirJr F.eWry Na>•?totartow t/D?irswU <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER MCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Rood kwitmetione before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREGUENCY SAMPLE] <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -: <br /> REQUIREMENT } . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , . .. ,. <br /> REQUIREMENT ?'.'r;; •; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,_•t . <br /> REQUIREMENT ;'•QGA '.'•? t <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 "Al! au n Pena 17 o lbw that this docnmem and all attachments were <br />TELEPHONE <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFICER <br />m <br />DATE <br />pmpa <br />l anon me dlrectton or uprr.hron In .ccord.rxe wlln .system eeagnad <br />to am re that g..Nfied prrsonnel Prwpedy g.ther and r•alualr tkr Inlrtnnatbn - <br />i submitted. Based on m7 tnqutrr of the person or persom who manage the Intem. <br />" er Ihose Pagers directly r PwW W for gaMrring the Informallom the inrorm 0- <br />rubwllted h• to the bent M m7 knowkdte and beW. Im,, amtrate. and complete. <br />.w <br />ftNne-I <br />&IONATURE OF PRINCWAI EXECUTIVE <br />I <br />e M <br />t ther <br />r <br />en.Iti <br />W <br />ttfi <br />fab <br />I <br />f <br />ti <br />b , <br /> am <br />ar <br />e <br />e a <br />e <br />p <br />e <br />m <br />ng <br />e <br />n <br />orma <br />on, <br />wr AREA <br /> <br />TYPED OR PRINTED <br />Inrludtng the possibility or fine and Imprisonment for knowing Iolatke <br />OFFICER OR AUTHORIZED AGENT <br />CODE NUMBER <br />YEAR <br />MO DAY <br />J <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reforence iN attachments hors) <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This iS a 4-pan form. PAGE OF