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PERMITTEE NAME/ADDRESS pwddrf«WgMwrrL°rrr°w (/D?rwy) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM WDESI <br />DISCHARGE MONITORING REPORT (D RI <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. NCY <br />FREO <br />U SAMPLE <br /> EX O <br />f <br /> ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <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 />NAMElT1TLE PRINCIPAL EXECUTNE OFFICER I rerldy under penalty ° Isw `list this doc-?menl ¦rsd all .ttachmwnh were, TELEPHONE DATE <br />prepared under my direction or superehlon In sccordance with .system deigned <br />. t to assure that quaMfled personnel properly plher and eesluale the Information <br />' <br />. f <br />submllied. Bard on mr inquiry o(th. Person or persons who mans=e the system, <br />W those persons directly responsible foe gathering the Information, the Information <br />sub <br />ill <br />d I <br />the bet *(m <br />knowled <br />t <br />e <br />nd b <br />#,f <br />Iro. <br />rat <br />nd <br />t <br />l <br />s, <br />y <br />m <br />e <br />o <br />g <br />a <br />t <br />, <br />, accu <br />e, a <br />comp <br />e <br />e. <br />I am swan that there are d <br />nlfluat <br />enalties (or <br />ubmitti <br />r <br />f <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />h. I <br />ati <br />n c- <br /> g <br />p <br />s <br />ng <br />a <br />n <br />orm <br />o <br />. <br />TYPED OR PRINTED Inrioding the possibility of Ilse and Imprisonment For knowing .W*Uoc& OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/anrtce &# •ffnchmenfa hard I (: t A T ih Al'' f' R 0 1:- <br />This is a 4-part fonn. PAGE OF <br />EPA Form 3320.1 (Rev. 3149) Previous editions may be used.