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PERMITTEE NAME/ADDRESS (7-&& F«NMryxr?Le atie ((D(Ql ewo) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM f/NPOESI <br />DISCHARGE MONITORING REPORT (OMRI <br />PERMIT NUMBER DISCHAltoE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OM15 No. 2040-0004 <br />r `>T~'-A Y1 V A Pcti D.. -T <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO <br />. <br /> <br />EX FREOUEIICY <br /> <br />OF <br />SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />- <br />I <br /> MEASUREMENT i <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br /> <br />1 "n "y u r pens ly o law that this doeumenl and all altachtnenll were T <br />TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I <br />DATE <br />prepared under my direction or wp <br />on In accordance with a syetem designed <br />/ to inure that quaMned personnel properly g21Mr and evaluate the Informatkm <br />' submltted. Bawd on my Inquiry of the person w persons who manage the system, <br />or thou persewe directly rerpondble for gathering the Information, the Information <br />wbmllled le, to the bet of my knowYdge and belief. trae, amtrate. and contplrle. <br />dnnnt <br />' 1 am aware that them are 11 <br />enaille for <br />bmfinn <br />false Info <br />BIONATVRE OF PRINCIPAL EXECUTIVE <br />ti <br />n <br /> 9 <br />p <br />w <br />g <br />rma <br />, <br />o <br />TYPED OR PRINTED Including the passibility or fine and lmprhoarnent ror knowlnr ebtauorm OFFICER OR AUTHORIZED AGENT CAE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference &N •rtachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is 8 4-part form" PAGE OF