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PERMITTEE NAMEIAODRESS anelude Faciht),14uneL«011011 11,hifferenu <br />NAME '_1MFi=!SN' <br />ADDRESS I NE LOADOU r <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />F-=PERMIT NUMBER DISCHARGE NUMBER T : <br />Form Approved. <br />OMB No. 2040-0004 <br />jr-KSN <br />_ R FC E CO 61' MONITORING PERIOD <br />FACILITY i_lAI-R R MIIFIE LOtAUOU' YEAR MO DAY YEAR MO [DAY X <br />LOCATION FROM TO <br />NOTE: Read Instructions before completing this form. <br />-'r NO FREQUENCY SAMPLE <br />QUANTITY OR LOADING QUALITY OR CONCENTRATION EX OF TYPE <br />PARAMETER <br />ANALYSIS <br />AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br /> SAMPLE <br /> MEASUREMENT <br />L <br /> F 71 <br />UC • , PERMIT is-r - <br /> <br />EFFt ' 9 V REQUIREMENT <br /> <br />C J <br /> SAMPLE <br /> MEASUREMENT <br />- <br />t <br />"t•J <br />. I.(? <br />E! R R D <br /> . <br />; r r i <br />F- ORT l S <br />C) <br /> PERMIT i v} r - <br />_ 1 r <br />k <br /> <br />REQUIREMENT . <br />. <br />F: t_t 1 -NI ALi.- }-.. ,f 0- <br />1., SAMPLE <br /> MEASUREMENT <br />Lllr•a I:' <br />QPAi- <br /> PERMIT n <br /> <br />1^(_i ?? VA1..?,!t REQUIREMENT <br />: '•.i SAMPLE <br />!J TREA-ffIEN'r PLHIy MEASUREMENT <br />l 1-41 i t - <br />t o F, l? <br /> PERMIT <br />It x st <br /> REQUIREMENT <br />F f t r t 1_i! <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> <br />ail#'tiQ <br />r T <br /> <br />?f( t_? <br /> <br />_ <br /> <br />` PERMIT s # u. .. , <br />1 <br />J REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> <br />MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />- TELEPHONE <br />DATE <br />1 ccmfy under penalty of IaA that this document and all attachments Acre <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />direction or supervision in accordance Aith a sysumdesigned , <br />d <br />d <br />d <br /> <br />un <br />er y <br />re <br />prepare <br />PeP <br />t <br />MunQon to assure that qualified Personnel properly gather and a alwvc the information <br />who manage the system. <br />iehATd A <br />n <br />pre <br />s <br />70 712;?33g <br />. <br />subnnttcd Rased nn my inquiry of the Pcrum or perso <br />ur <br />f <br />i <br />h 09 04 O <br />' <br />artna <br />m <br />e m <br />on, t <br />GCB Lri3 P 1 iP.nt or those persons dtr«tly responsible Ibr gathering the informat <br />ktx?Al.-dge and belief true, accurate. and complete- SIGNATURE OF PRINCIPAL EXECUTIVE <br />t <br />f m <br />h <br />h ? <br /> y <br />es <br />o <br />submmed rs. m t <br />e <br />1 in aµarc that there are s entficant penalties for submitting false information. OFFICER OR AUTHORIZED AGENT C??E NUMBER YEAR MO DAY <br />tvn?n nta DGIWTFt1 nrludine the possibility of fine and imprisonment for knowing %'tolation, <br />-0`1,-1FAENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />P T ``' IT cl )T3. <br />• ;T <br />;r <br />13. 6. ANY ADD I ; a ?:ir?r',L f C <br />Form 3320-1 (Rev. 3199) Previous editions may be used. <br />I OF PROOF REQUIREMEN <br />LOUR S <br />