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PERMITTEE NAME/ADDRESS t nei6 F^-,k ryN.a?Locatton t/DWb,-u) <br />NAME <br />ADDRESS 31-iW -114,11 13 <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHMIOE ELIMINATION 4YSTEM (INPDESJ <br />DISCHARGE MONITORING REPORT (DMR/ <br />PERMIT NUMBER 04SCHAAGE 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 inetmctlone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREDUENCr <br />OF SAMPLE <br /> <br />TYPE <br /> AruALrsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER t certny wriJW pens y aw that this docunrM and al .uachmente ,rre TELEPHONE DATE <br />p-pared under my dl-tton or Supeeyllon In accord- with a system designed <br />to aarure that qualified Personnel Peel gather and ey Nuale It. Inrnematlon <br />- mbmltted. lased on my inquiry or the parson or pen who manage the ¦yorm, <br />or those perwas directly responsible for gathering the Inrormatlen, the Intormatlon <br />submllted K to the bet of my bnawledge and beler, true, arcorate, and complete. <br />IGNATURE OF PRINCIPAL EXECUTIVE <br /> I am a- that there are 9l9rdM1can1 penalle for mbmttdng rahe information, S AREA <br />TYPED OR PRINTED Including the poadbllty of nne and Imprisonment ror knowing lolatl ? OFFICER OR AUTHORIZED AGENT COOS NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS !Reference aM attachments here! <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This is a 4-part