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PERMITTEE NAME/ADDRESS(Tnc&br.tNryNo.?LxafallfD(f. 1) <br />NAME <br />ADDRESS <br />? 754 <br />04it" ??Cl i#11`rcf3 <br />FACILITY R NO. ill I NE <br />LOCATION ER'SET -`. -J1434 <br />:?}? FI F iil=slFt, ?lZF?I ii=AiT <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (/NPOESI <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER 04SCHAAGE NUMEER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />..k;N?FF <br />NOTE: Read Matnictlona before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANAtrsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c> - o - <br /> REQUIREMENT X i t` UN, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT t'1 ;h; T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i NST NAX <br /> SAMPLE <br /> MEASUREMENT <br />I f 's PERMIT ?Ef f: r. ,ct<#ii #9E#k## 1Lrt'' <br /> REQUIREMENT ?L}t5 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT RI-'TDF)-' -?EFIDRT <br /> REQUIREMENT r ;aXLY MX <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT P (3F T i <br /> REQUIREMENT ;VyT Mr: ' <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEfnnE PRINCIPAL EXECUTIVE OFFICER I ce l.1y r, pens iy c bw that thH docvmrnt and it attachments wers <br />TELEPHONE <br />DATE <br />Prepared under my direction or superetslon In accordance with • system designed <br />to more that quaNfled perwnnel properly gather and evaluate the Information <br />submitted. lived on my inquiry or the person a persons who manage the system, <br />or those persnns dimity responsible for gathering the Information, the lmronnation <br />d K io th <br />it <br />b <br />t <br />r m <br />knowled <br />I- <br />l <br />d c <br />m <br />b <br />d b <br />li <br />f <br />l <br />t . <br />su <br />e <br />es <br />o <br />y <br />ge an <br />e <br />e <br />, <br />*. sccum <br />e. an <br />p <br />e. <br />m <br />te <br />o <br />e <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />t <br />t <br />itti <br />i <br />r <br />tl <br />h <br />h <br />n <br />f <br />f <br />i _ y <br />TYPED OR PRINTED un <br />n <br />I ¦m aware t <br />a <br />t <br />ere are sigN <br />penalcw <br />or subm <br />ng <br />a <br />n <br />orma <br />on. <br />including the possibility of fine and Imprisonment for knowing Aolatiotn OFFICER OR AUTHORIZED AGENT CAIEAJ ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference 0 strachments here) <br />.. __ CT'"t'T•?i. [- ^1_'!i T r-, r..? .=? 'r -i yr ,: t•. <br />EPA Form 3320-1 (Rev. 3519) Previous editions may be used This is a 4-Pert form. PAGE OF <br />