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PERMITTEE NAME ADDRESS <br />NAME <br />ADDRESS t?l ?_t H LOAL?O4J1 <br />FACILITY <br />LOCATION <br />,. " _urrt:r ul!iCr:.=1cE s'rsiEr.a (fIPDES) n Approvec. <br />u',10 No. 204000(14 <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER _ ,. i,' Ot !'( j <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO 4 X <br />NOTE: Read Instructions before comoletino this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />? OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ## ± ui s: E?. ?=#; #3FCi 9. O 141CE.% 'PA..Ii <br /> REQUIREMENT .'11 : N i'itsk"I `' <br /> SAMPLE ;. ; .q. <br /> MEASUREMENT <br /> PERMIT ?.. # ,.. if '? # sE i 5 70 <br /> REQUIREMENT :'vI)/? H?'i; DT+: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a:: , <r:r it7 ? p•" #4F. aiRt; 41 PPP 01RT - '5 _ <br /> REQUIREMENT ?.t?Ctr?, r1`J <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT # s1*?,... ? rf #i?1F#v ,.. ki!##it1- WTr'E; <br /> REQUIREMENT ar}L; : j- _; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :.sfi ?it:r.cti? r.## lfklt•##it ii*#r## i0 eiyTlivi i?!F?' <br /> REQUIREMENT tfr ; ; GF(?IT <br /> SAMPLE i 03) tt >- <br />_ i R- A 1 1,1LNv 1 _ MEASUREMENT <br /> PERMIT E.PORT REPOfT i C'riTIi-•I jC. Cis <br /> REQUIREMENT : ,A AVG UA I LY <br /> SAMPLE it ## + ;•, :'. r s ;r <br /> MEASUREMENT <br /> PERMIT .. Y_•4 t: '.., <br />L- it* f tr fi <br />- REPORT P EPORT <br />Tp <br /> REQUIREMENT SODA AV'e; !- 1 L?,' M', <br />NAME,/TITLE PRINCIPAL EXECUTIVE OFFICER I wmt) under penalty of law that this dueument and all anaehments were TELEPHONE DATE <br /> prepared under m% direction or supervision in accordance with a sy_'tern designed <br /> to assure that quahfred peno.' nnel properly gather and cyaluare the information <br /> submitted. Erased on my inquiry of the person or persons w•ho manage the system, <br /> or tho,e pcr onas directly responsible for gathering the mf,rmation. the intbrmatton <br /> ,ubmined is, to the best of my knowledge and hehcf, true, accurate. and complete <br />I <br />w <br />th <br />t th <br />si <br />fi <br />t <br />lti <br />suM <br />ni <br />l <br />fo <br />f <br />f <br />ti SIGNAT RE OF PRINCIPAL EXECUTIVE <br />- <br />t <br />TYPED OR PRINTED gni <br />can <br />pena <br />ng <br />a <br />sc in <br />sin a <br />are <br />a <br />ere are <br />es <br />r <br />ut <br />orma <br />on, <br />urludrng the p„?.s ihiluy of fine and imprisonment for knowing Violations OFFI ER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> . CODE <br />}-'F`, PREC IP EVFmT SUL• jE(.•f iQ BURDEN <br />OF PROOF TN, <br />L :r .ION WITHIN 42, t1P17; <br />EPA Form 3320-1 (Rev. 3x'99) Previous editions may be used. I_ PAGE OF