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PERMITTEE NAME/ADDRESSt7.c6kiaro#yNo.WLnr.rfar?D($W-9) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTE764 NPDES/ <br />DISCHARGE MONITORING REPORT /DMRI <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 />57 7AY/Of? 1 ?vr? 1 ll?/fGr1 <br />NOTE: Road Inatructlone before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCV <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE c J J <br /> MEASUREMENT <br /> PERMIT r <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEfMLE PRINCIPAL EXECUTIVE OFFICER I Krwr wnd? pen' tT o low that this exununf and .w .t1whment, were <br />TELEPHONE <br />DATE <br />pnp.red -der mT dlrectlon a super.Hon In .ccordaon with . systern designed <br />to anus IAN q..MMd personnef properly gather and e,.fuel, Ike Information <br />Abmilted. Bred on my tngt,ty or the person ne perk„ who m,an.te the friterm <br />or those peeam, dlmdly -ponAble for fathering the InFortn.tlm. the Info tbn <br />anbmltled K to the beat of me knowledge and btkef. Irwe, a mte, and ecImplete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />l <br /> I am aware that then an s <br />grdMnnt penalties for submitting false Informstbn. <br />TYPED PRINTED InAuding the poadblMtr of tine and lmprfsonment for knowing violation'. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Reforenco *# attachments Aaral <br />EPA Form 3320-1 (Rev 3199) Prevrous edfions may be used 'H us IS a 4-pari (Oral. PAGE OF