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PERMITTEE NAME/ADDRESS,/,,,lad, Frxdir. 1. u • C.. ur:-o,i 1wt-,w <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER QISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCYI <br />OF SAMPLE <br /> EX I TYPE <br /> ANALYS <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT J? <br />t C t l ! - SAMPLE <br /> MEASUREMENT <br /> PERMIT ? •t ) 1' C R T ' F"0.9 T T . <br />?''I ',.1f 11 r c?r;rn?c REQUIREMENT <br /> <br /> SAMPLE <br />LE <br />"'VRF MEASUREMENT <br />• PERMIT t- t - _ ;KAt3 <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I c-f} under penalty of law that this document and all attachments were TELEPHONE DATE <br />prepared under my direction or supervision in accordance with a system designed <br />i to assure that qualified personnel properly gather and evaluate the information _ - - -? <br />yam " <br />submitted. Baled on my mquim of the person or persons who manage the ."stern. - <br />?? • - - <br />the mfi?rmation <br />onstbie for gathering the information <br />on <br />dirwiv res <br />r <br />th - <br />. <br />ose pe <br />s <br />p <br />or <br />s <br />,--? submitted is. to the best of my knowledge and belief. true. accurate. and complete SIGNATURE OF PRINCIPAL EXECUTIVE - - <br />I am aware that there are significant penalties for submitting fats information. <br />i <br />l <br />f <br />k OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />now <br />ng eio <br />auor.? <br />or <br />TYPED OR PRINTED including the possibilit} of fine and imprisonment CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3199) Previous editions may De used. <br />