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PERMITTEE NAME/ADDRESS (heekdr FwoyNo wLw-ttew 1/D(p-,) NATIONAL POLLUTANT DISCHARGE EUMINATION SYSTEM /NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />IiUX PERMIT NUMBER Di111N1GENLM SER <br />'.ERSET :_ <br />FACILITY < G OR N CF6% MONITORING PERIOD <br />LOCATION "IzRSET Cu -1 YEAR MO I DAY YEAR M DA <br />FROM _ TO <br />- •1ES T. COOPER, EXEC V <br />Form Approved. <br />OMB No. 2040-0004 <br />MIN-)1• <br />F - FIi <br />I?ISCHAR6t u LLi,?, Lrt Lh <br />X <br />NOTE: Reed kwtruetlorw before complet" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, ENCY <br />F <br />r SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX AMNALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ' <br /> REQUIREMENT MINIMUM i`I:+XIMUM r30NT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT x j _ <br /> REQUIREMENT 3 ?'DA r;'.%t3 MY 7 D AV Ff! <br /> SAMPLE <br />aS ?E MEASUREMENT <br /> <br /> PERMIT -it <br />o <br />- <br /> REQUIREMENT :30DA AVG DAILY MX MEIN i <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />L REQUIREMENT I NST riA X i F <br />1. SAMPLE <br /> MEASUREMENT <br /> - <br /> <br /> <br /> <br />N'1 PERMIT <br /> <br /> <br />REQUIREMENT <br /> <br /> <br />3UDA At)C= <br />REP UR7 <br /> <br />DAILY" NX <br />tie <br />r. <br /> <br />k <br />t. r_ <br /> <br />7 <br /> <br />-TAT <br /> SAMPLE <br />..!AL MEASUREMENT <br /> <br />-6 1 0 PERMIT F-?- UK I <br />. . <br />i..+.?:!' l p: ,: • REQUIREMENT I MAX <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1'enny 'r'&' Pen- I '(I-' that thh da rr nl and uI ail-'hment- were <br />P"P-red ender my dietion wmp.-hion In -cvd-nce TELEPHONE <br />.Ith - rTttem dulgned <br />DATE <br />le a"'m that 41e-Mthd PwnmO ftfl P'OPery gather and fe-Iu-If IM In(ornell{On <br />submitted. Stt-ed on my Ingelry or the port w peramne he nonage the -stem, --- <br />- "how persmr directly reeporelbk fw gathering the Inrwm-tlon, the Inrornoo,rm <br />. r submitted I-, to the bill o( my kne.tedgt and bolter, Irvt, ocmmle, and eompiNe. d <br />1 <br />I -m -.-n that mere on elgmrifk-nt pendtk- for abmlltlng War Inrorm-tlon <br />f10NATt/RE OF ?RINCg?AL XECt1TIVE <br />TYPED OR PRINTED , <br />Indeding ttx pr .dblllty or llne ¦nd I-ItAwnment Iw kne.Ing lelauwei OFFICER OR AUTHORIZED AGENT AIEA 1 <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPt.ANA I JUN Ur nnT vlvt N I IVNb /rtererence off •rracnmanrs nere/ <br />PERIOD REPORTS <br />OIL & GREASE - SEE I. B. 1. D <br />EPA Forth 3320-1 (Rev. 3/99) Previous editions may be used