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PERMITTEE NAME/ADDFtESS (7nn6 • Foraf Na.?L. wi m ((DlpbwuJ NATIONAL POLLUTANT OISCHAAOE ELIMINATION SYSTEM (NPOES) <br />NAME DISCHARGE MONITORING REPORT (D R/ <br />ADDRESS <br />'. BOX S31-. PERMIT NUMBER DISCHARGE NUMIkFR <br />'ERSET MONITORING PERIOD <br />FACILITY BORN CRK W: ELv. CRK M11VE5 <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ?ERSET Co E31 FROM TO <br />;11;: CZ T C nnpFR, FXFr V P <br />MINOR <br />( SUBR MH ) <br />F - FINAL <br />SURF RUNG <br />Form Approved. <br />OMB No 2040-0004. <br /> <br />NOTE: Reed kmtructlo4 before completing thh fix-. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE , <br /> MEASUREMENT <br /> PERMIT #31 REPORT #itis# x- - CE/ I UAL <br /> REQUIREMENT INST MAY <br />., <br />MONT' <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER I mredy under pen. y o In. that tins document and all anachmenb were TELEPHONE <br />vW <br />I <br />ith <br />t <br />i <br />d <br />d <br />i <br />d DATE <br />a sys <br />em <br />es <br />gne <br />prepared under my direct <br />on or mprr <br />m <br />n accor <br />ance w <br />to inure that qualified personnel properly gather and evaluate the Information _ <br />" - oubmltled. bawd on my Inquiry of the person or persons who manage the system. <br />eraoro dimity respo"Irk for gathering the Informadom <br />the Information <br />or those <br />r <br />, <br />p <br />- <br />i . <br />47 submitted Is, to the bet of my knowledge and better. true, securale, and compkk. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am ¦war that there are slgnif Ant penalties for submitting false Information, ARE <br />TYPED OR PRINTED Including the possibility of fine and Imprisonment for knowing Oolauoms OFFICER OR AUTHORIZED AGENT ODE NUMBER <br />C YEAR MO =DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments h rral <br />1tZYR. ?:?.?^ nRF?.r? <br />-7 FAri r. ^rl. T^? LMT APPI_TED FOR <br />_ " fQR11 PAGE OF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. T? .. S -, is.a : - P8rt .