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PERMITTEE NAME/ADDRESS Nnclwle Fa ilia V me2ncrrnon iifDgerenrr <br />NAME <br />ADDRESS l 1'41 <br />FACILITY <br />LOCATION <br />IANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (N/POES) <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 />NOTE: Read Instructions before 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 .. , FT L 3 <br />1_ REQUIREMENT JCC;r-. r <br /> SAMPLE <br />* t r/, . MEASUREMENT <br />ij PERMIT r '.?t? R:_"tTF.'i <br />r 1F' REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />r t _ 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 I ecrtffy under penalp ,, law that this document and all anachntenr, ,-Acre <br />wi <br />r <br />d <br />d <br />d <br />i <br />i <br />d <br />h <br />d <br />d TELEPHONE DATE <br />_ <br />C <br />'? G <br />'••L-'" <br />' ? epare <br />un <br />er my <br />irection or wperv <br />, <br />p <br />on to accor <br />ance <br />t <br />a wstem <br />eigne <br />to assure that qualified pers mnel properly gather and caaluau the information <br />b <br />d <br />d <br />f <br />h <br />, <br />?-?? <br />/ <br />r <br />? <br />•- - mitte <br />on m} inquiry o <br />t <br />su <br />Bau <br />e person or pers s whir manage the <br />system. - <br /> or thnsc persons directly responsible fot gathering the m1brmaurm, the mftxmation <br /> nt <br />d <br />i <br />th <br />h <br />h <br />t <br />f <br />k <br />l <br />d <br />d b <br />l <br />f <br />d <br />l <br /> <br />r l u <br />m <br />e <br />n. <br />n <br />es <br />o <br />e <br />my <br />now <br />e <br />ge an <br />e <br />ie <br />. true, accurate, an <br />coinp <br />ete. <br />I « <br />ac vha+ !h <br />ire si <br />nificant <br />enalties for submutm <br />faLu information <br />VI; <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />S <br />TYPED PRINTED . <br />, <br />g <br />p <br />g <br />. <br />I r <br />x..;ihihty of finc and imprisonment for Lnowin <br />violations OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> _ <br />I <br />g CODE <br />S AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3;99) Previous editions may be used. D0074 / ()P. I i ? 4-part form.