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PERMITTEE NAME,+ADDRESS ilndnde Furilin ,ti'rmrc'Iw ntron d!)i//prcnrl <br />NAME _ <br />ADDRESS fC1'1 1 f-'!'.: <br />DAD ^ ? C' <br />FACILITY ,? ?7o n r • i t:. <br />LOCATION <br />1 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER - : NAL _ C NAS i <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO k <br />NOTE: Read Instructions before COmDleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE = <br /> MEASUREMENT <br /> PERMIT _ #;i:t#-a b. c: r Inli fi •'FHi? <br />i REQUIREMENT I'1 11'i I It' Ll 9 !'t Tt 1 <br /> SAMPLE T <br /> MEASUREMENT <br /> PERMIT # rtr-rt. t r st f;f;r?i :30 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT #r• :?i xµ,::.. (i. i_t?E/ <br /> REQUIREMENT v } . N L, <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT REPORT i' SCE! <br /> REQUIREMENT CIDA <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t a- 10 <br /> REQUIREMENT r <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />cr i C <br />REPORT <br />ti:? .. <br />i.a-k ii1• <br />j1r.^ . I(? <br />?C:?!:L'i, <br /> REQUIREMENT DA 9:1_ •/ MX <br />l } <br /> SAMPLE r? z <br /> MEASUREMENT <br /> PERMIT x;e RFi'ORT E` ! :r -f r±f : ;?'i•1: ?# ?1 C? .'' ?!` =,I.iril, <br /> REQUIREMENT r.tt; ;{ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cer m under penalty or law that thi, document and all attachments were TELEPHONE DATE <br /> <br />r !_ prepared under ma dir?tion or supervision in accordance with a .v tern designed <br />to assure that quahhid personnel propcrly gather and evaluate the infIormanon <br /> <br />' <br />? <br />' <br />- <br /> submmed Based on my inquiry of the per.on or persons who manage the,,. stem. ?• ; <br />1jy <br />?. ?? <br />?f j?c • .,. <br />- or gwsc prrsons directly responsible rcx gathering the mfirmntirnt <br />the intorrnation k -j ' <br /> . <br />ai <br />lete <br />t <br />f t <br />l <br />d <br />d h <br />f <br />tru <br />acc <br />rat <br />and com <br />b <br />t <br />th <br />b <br />k <br />d ' <br />L , o <br />es <br />now <br />ge an <br />, <br />e, <br />u <br />e, <br />p <br />. <br />mitte <br />u, <br />o <br />e <br />o <br />m <br />e <br />e <br />su <br />f <br />fo <br />h <br />i <br />i <br />l <br />b <br />r <br />i SIGNATURE OF PRINCIP EXECUTIVE <br />- u:, L-r ,u <br />nu«mg <br />e <br />rmation. <br />I am aware that t <br />ere are s <br />gnif <br />cant pena <br />se <br />n <br />i <br />h <br />f <br />k <br />l <br />t <br />b <br />f <br />i <br />d OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED tc o <br />ne an <br />mtpri-nment <br />or <br />n- <br />ng vio <br />a <br />ions <br />including the po ssi <br />i <br />f CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIUNS (Hererence an arracnmenrs nerej <br />EC 1P EVENT SUBJECT TO BURDEN OF PROOF REQU I R T=P1f:rJT8 T P4 <br />TO THE DIVISION WITHIN 46 HOUR. <br />s. <br />-Aq <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. This is ,a 4_Itaq form. r Nlac