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PERMITTEE NAME/ADDRESS (yne66FarbtyrNw?L e(,- Dlpfw.nr) <br />NAME <br />ADDRESS <br />BOX <br />NIA -? <br />FACILITY I E NG. <br />LOCATION :NIA l? L <br />Form Approved. POLLUTANT DISCHARGE EUMINATION SYSTEIM (NPOE,S/ DISCHARGE MONITORING REPORT IDMRI OMB No 2040 0004 <br />PERMIT NUMBER 04SCHAAGE NUMBER 1 NAL DEt_ i f.} <br />Bl? MONITORING PERIOD ER TRL DlC OR UNMD TRIH <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Reed Metructlorn before complet" this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX S <br />S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALY <br />I <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT fl#.#s ?? x t. ::#is,r• <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> : <br />fi <br /> PERMIT ?t x tFfa c P. 'ri <br />' 1 , <br />; <br /> REQUIREMENT - - <br />( i'iiai <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT r? _ 1-• <br />. F: `F?p i? <br /> REQUIREMENT ; 1. N <br />. `I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ` <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT ::. <br /> SAMPLE <br /> MEASUREMENT <br />- -. <br />;=P R 1T <br />PERMIT r _ <br />, <br />2 MAX <br />REQUIREMENT T <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER I Rruly under pens ly o (law that this dorumenl and all atlwhm is were TELEPHONE <br />prepared Ynder my directlon or wperrl/on In accordance with a system dealgned DATE <br />to amurt that quaNn d personnel properly gather and evaluate the Infnrmallon <br />submitted. board on my Inquiry of the person or persons who manste the system, <br />or those penoro dlrsctly responsible for gathering the Infornuelion. The Information <br />submitted H. to the best or my knowledge and belle!, true, accurate. and complete. <br />EXECUTNE <br />IN <br />WA ' <br /> I am aware that there are dgrdflcani penalties roc wbmlttlnt false Information, SIGNATURE OF PR <br />C <br />L <br />OR AUTHORIZED AGENT <br />I <br />E A A <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED PRMITED inchsdlnt the possibility or fine and Imprisonment for knowing violations. OFF <br />C <br />R CODE <br /> <br />COMMENTS AND EXPLANATION UP- An i vwt-rn l IVrga frrerwranc• on at,-...s..rrra re.r .r <br />;a npFrt(a i*..rrr '{c Ci.^,?M?n TF GI_AiM lPPrlVF LY wfGI <br />• - This is a 4-part form PAGE of <br />EPA Form WO-1 (Rev 3/99) Previous editions may be used