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PERMITTEE NAME/ADDRESS (YwoYb FerOrrNsaw?tse.rim VD(liwwaq <br />NAME <br />ADDRESS <br />- h,i=R <br />FACILfTY -uW''' <br />LOCATION -KEh i; <br />NATIONAL POLLUTANT 04SCHAROE ELIMINATION SYSTEM /NPDES) <br />DISCHARGE MONITORING REPORT IDMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO OAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read kntructlone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREOUEMCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ", - % <br />r : I <br /> MEASUREMENT _ L <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 t <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER n fe rly r pens y ° law that thh dorument and all ali.chments were TELEPHONE DATE <br />prepared ruder my direction or supervision In arcordann with ¦ system designed <br />to Maps" that qualified perso-4 Property t.tMr and ev.lnale the Information , <br />.. submitted. Bred on my inquiry o/ the persow oe persona who msnsgv the system, <br />or those persons dlr 117 resporolbk for gathering the Inrortnatinn, the InfnrmaUon <br />submitted h, to the bat of my Anow,Wte and be#&,(, Irse. accurate, and compile. <br />NATURE OF PRINCJPAL EXECUTIVE <br />I <br /> I am swan Ihal then art sltniflcaM Penalties fur submitting War Infnrrnatlon, S <br />G AREA <br />TYPED OR PRINTED Including Me possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT ' <br />CODE NUMBER YEAR MO DAY <br />COMMENTS ANDEXpLANATION OFANYVIOLATIONS (Reference &#attachments herel n PRFCIP FVFNT 7S CLAIMED IF CLAIM 1?I•'PROVEJ! 1_3Y WQNCD, <br />EPA Form 3320-1 (Rev. 3/99) Previous ed'Ibons may be used This is a 4-pan form. PAGE OF