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PERMIT-TEE NAME/ADDRESS ,Ir.. laJr F:N d,h \.u.., .., ;; ? 1! ••l rnn NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NFDE$) Form Approved. <br />OMB NO. 2040-0004 <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER RSLAN <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />- FROM TO ,+C-• <br />NOTE: Read Instructions before completing this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. EDUENCY <br />FR SAMPLE <br /> EX OF TYPE <br /> ANALYSIS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ; Itjr T <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 I certify under rwnalq of law that this &wumcnt and all attachmcnis were TELEPHONE DATE <br /> <br />-- - prepared under my atrccuun or supervision in accordance with it system designed <br />F to assure that qualified pcrsonncl properly wither and evaluate the information <br />b <br />it <br />f th <br />l <br />B <br />d <br />i <br />i <br />h <br />h <br />y%- -?--' - <br /> su <br />m <br />ta <br />- <br />ase <br />on my <br />nqu <br />ry o <br />e person or perscros w <br />o nwnagc t <br />e swan, <br /> or [host prrwtu d:rctitly resporoible for gathering the minrmatrcm, the tnforrnatiun -? - •- -- <br />f <br />i t <br />' suhmitted is. to the best of my knowledge and belief. tn,c. arcur,,te, and complete <br />m <br />w <br />t th <br />h, <br />! <br />I <br />th <br />if <br />t <br />ln <br />b <br />•l <br />P SIGNATURE OF PRINCIPAL EXECUTIVE <br />?? <br />TYPEWOR PRINTED mre <br />ere are sign <br />ican <br />r 5u <br />nar.vr_ <br />.,nnan,.r. <br />a <br />a <br />a <br />pena <br />c, <br />. <br />:r :n <br />including the pos,thditt of fine and impn..mm, i t,. 4.;;. •.. v: .., ;,r;, :,> OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous edaiors may be use, This is a 4-part f6mi.