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PERMITTEE NAME;ADDRESS,f,, i v. <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />DISCHARGE MONITORING REPORT (OMR) <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 />NOTE: Read InstrLiCUonS hefore Completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />' MEASUREMENT <br /> PERMIT <br />_ES5 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 <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 l certify under penalty of law that this document and tdl attachment, were TELEPHONE DATE <br /> <br />'... prepared under my direction or supervision in accordance with is s so:m devgned <br />/ f? i•, : surc that qualified peminnel prnpertc gather and esaluatc the information <br />suhmitted. Haled on my inquiry of the pemu) or per om wlto manage the system. " <br /> <br />/ <br />- <br />- <br /> the information <br />or those perwms directly responsihle for gathering the mfcrtnaunn - <br />'-- -% - <br />-' <br />-?- " r <br />! - <br />- - <br />suhmmed fs, t.., the hen of my knowledge and belief, tow, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am d:.v t.h.rr arc significant penalties for submitting false inforinanon. <br />OFFICER OR AUTHORIZED AGENT <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED a u.. : p••>, hih of line ¢nd imprisonment ti,r knuwmg ciahitinns. <br />viv i.raa ia?i?.a tncacr craa.c c.. caaaaa.r,.??c?.a? .?c. c? <br />L;VMMCIV 1Q HI`IU r-^VL-MiVM11w1• yr mine <br />;,R. PREC TP. BF_E I A 1 , PG 3 F^F' <br />EPA Form 3320-1 (Rev. 3M) Previous editions may be used. ; . 3 hid is a-4,pan Ionn. PAGE OF