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i <br />,,;I iEE. t:ar,L ES <br />t•iktoc <br />ADDRESS t= <br />RF <br />FACILITY r, <br />LOCATION R f <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DA4R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br /> <br />NOTF• Rpnd Incintrhorta hpfnrp rmmnlnlinci this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT l fi :r E. 7 T. E , j: <br /> REQUIREMENT <br />1`'I f?Pl Th' <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif. uodet penalty of law that mt.. document and all attachments were <br />prgmred under me dinxnon or supen tstnn in accordance with a svstem desi <br />ned TELEPHONE DATE <br />g <br />- ,,T, 1 , <br />_. --• to assure that quaiffied Nronnel properl% gather and evaluate the mtbrmatton <br />, <br />submittal Rased on my inquiry of the persm or persons who manage the system. - ' . <br />or those persons direcliv r-sporsible for gathering the infcmnation, the infontmhon <br />ubmitted ts <br />to the best of my knowledge and belief <br />true <br />accurate <br />and complete <br />, <br />, <br />, <br />. <br />. <br />I .:m :rsare that there are significant penalties for submitting false information. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED'OR PRINTED c.:ice the {xssibdity of fine and imprisonment for knowing , it4auons OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />--......_...... "..., ?...._....,....,......_... ...,_.-...,,.. ,. o.o.a...,? a„ a..o,,..,.,?,..? ..?.?? 'f? ZFC I#' 17' VFh!? - ?: rF i ?. .. P'. ? F ID R c, z:,-,r , ., r •.,r_p,:-f. <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. `T}ll$ 15 3 4-part fon-1. PAGE OF