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PERMITTEE NAME/ADDRESSpnr6&F--OJYN..?L«.nen(/D(pk.wq <br />NAME <br />ADDRESS <br />FACILITY <br />LOCA T)ON <br />NATIONAL POLLUTANT OISCHARGE ELIMINATION SYSTEM //NPOESI <br />DISCHARGE MONITORING REPORT (DMR) <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 Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FtIEOVENCr <br />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 /> <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 /> <br />1 cerlrly u r pens ty o ¦w that this down mrnt and .11 altachmenta went T <br />ELEPHONE <br />NAMEfTITLE PRINCIPAL EXECUTNE OFFICER <br />DATE <br />pmpartd under my dimllon or wpr fOm In arcordaner wl(h. artem dedgned <br />. <br />. to aawrt that qualified personnel property gatMr and eyalu.tr the Intorwotlon <br />fobmllled. Dosed m my Inquiry of the prrtattt w pertoes who manage the rrtem, <br />or those persars directly nnporrdbla for gathering the Inforwutlnn, the Inrormallon r <br />5 <br />wbmitled b, to the bear of my knowledge and belief. lrve, arcuratr, and eorrtpletr. <br />I am aware that there art significant <br />enaltle For wbmdlnn <br />raker inrarm <br />tl <br />SIGNATURE OF PRINCIPAL EXECUTIVE I-.• <br />.- <br /> p <br />g <br />a <br />on, <br />a <br />TYPED OR PRINTED Including the Possibility of fine end Imp. <br />m meet for knowing Hdatloa OFFICER OR AUTHORIZED AGENT COOS NUMBER YEAR M0 DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference aM attachments here/ Rf_'i'IP 7.J T T._ C AIh'!ED. I. - 1_f?T _fn ,1rP.tr0'??r h 3 2 ?' 1 <br />:•hI . 9 IF _ ti ?CU <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF