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PERMITTEE NAME/ADDRESS Onclude Faciltrv N um-lorarma IjDiff roan <br />NAME <br />Lido <br />ADDRESS "4;E <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 /> <br />X <br />NOTE: Read Instructions before completing 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 : : (.. ?31 T: <br />,. T-. REQUIREMENT TH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT < t <br /> REQUIREMENT !IL_IN T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c -. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />F G '._i' - REQUIREMENT ;- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />r MEASUREMENT <br /> PERMIT F -- : . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - t crT p{-;c_? f3E°vR <br /> REQUIREMENT <br />NAME,)TITLE PRINCIPAL EXECUTIVE OFFICER I ccrtif% under penal of Ina that this document and all attachments were TELEPHONE DATE <br /> prepared under my direction or supervision in accordance with a system designed <br />_ <br />?i .?? to assure that qualified personnel propcrly gather and valuate the mfumution <br />a _ r <br />J <br />• _- <br />y' submitted Based on my inquiry of the person or persons who manage the system, <br /> or those persons dimctfy responsible for gathering the information the information Ire, - <br />l <br /> submitted is. ;o the tx.•st of my knowledge and belief, true, accurate, and complete. <br />b <br />i <br />fi <br />l <br />f <br />l <br />f SIGNATURE OF PRINCIPAL EXECUTIVE L <br />' <br /> ties for su <br />mitting <br />a <br />ormaunr' <br />1 am aware chat th re are signi <br />cant pena <br />se <br />n <br />h <br />d <br />t f <br />k <br />i <br />i <br />l <br />i <br />f <br />i <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br />TYPEb OR PRINTED o <br />ty o <br />t <br />ne an <br />Impr <br />sonmen <br />or <br />now <br />ng v <br />at <br />ons <br />including th pmsihi CODE <br />I.UMMLNIA ANU r-ArLANAIIUN Vr ANT VIULAIIVNJ IrIViVItrIIL W an 0114vn111WIIgo neral <br />:R PRECIP. EVEF,,)'i - SEE 1. A. 1, PG. 3. FOR REGUIREMENTS. <br />SAMPI.ING 1NSTF:UCTIONS - I. C. 7 , PG 14. <br />EPA Form 3320-1 (Rev. 3.199) Previous editions may be used. 00 17 7 . This is a 4-part form.