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PERMITTEE NAME/ADDRESS rlnrlade Facilirn .Vamc'Lrxatron fif t)ij crenp <br />NAME <br />ADDRESS r <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Farm Approved. <br />OMB No. 2040.0004 <br />,a' <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREDUENCY <br />OF SAMPLE <br /> 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 <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 1 -iii, under penalty of law that this document and all attachments were <br />d <br />d <br />d <br />h <br />d <br />d <br />d TELEPHONE DATE <br />_ prepare <br />un <br />er ms <br />irection or supen tstun to accor <br />ance wn <br />a s%.%wrn <br />esigne <br />/ to assure that qualified personnel properly gather and evaluate the information <br />- -- -- <br /> iubrni[ud. Based on my inquiry of the person or persons who rinamuc the system. f <br /> or those perons directly responsihlc for gathering the mformatian, the information ` <br /> submitted is. to the hest of my knowledge and Wief, true. accurate. and complete. SIGNATURE Of PRINCIPAL EXECUTIVE <br /> 1 am aware that there arc.i <br />nificant penalties for submittin <br />false mtionnatnon <br /> <br />TYPED QR PRINTED g <br />' <br />g <br />including the pos,ibiht? ,d tine and imps onment for knowing siolation. OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />E{. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. CIO22' , This ISM - >Z I01Itt.