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RECENEV roved <br />Form A <br />PERMITTFE NAME/ADDRESS (taritJ Forary)v .?Le .ttot ((Dlf wrt) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTDA (NPOESI <br />DISCHARGE MONITORING REPORT IDMR) pp <br />OMB No 2040-0004 <br />NAME oO <br />ADDR 5 2 <br />v <br />AFR 1 J <br />ESS ision of <br />d Sa ety n, <br />PERMIT NUMBER DISCHARGE Nt1MEER <br /> Div <br />a <br /> Min"'g MONITORING PERIOD <br />FACILITY YEAR MO DAY YEAR MO DAY <br />LOCATION FR OM TO <br /> NOTE: Read Irtatructlorte before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />T <br />) <br /> REQUIREMEN <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />` <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE -') 1 <br /> MEASUREMENT '? -J <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT n / 1 <br /> <br /> PERMIT <br />7 i?c <br /> REQUIREMENT <br /> SAMPLE L 7 <br /> MEASUREMENT li <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I -1.1y under penalty ° law that Ihb dorvmeal and ail .Ilach.mb were TELEPHONE DATE <br />prepared under .y dimilon or super.lalow In amordanre with a system designed <br />to ivinum that qualified personnel property galher and evaluate IM Infonnallon <br />)) [ ,) l >I" '1 L G v <br />itt <br />d on <br />of the <br />erson ar <br />b <br />d <br />Ba <br />In <br />ulr <br />r <br />who <br />e th <br />t <br />. <br />y <br />au <br />. <br />e <br />. <br />q <br />r <br />p <br />pe <br />sons <br />manag <br />e tri <br />e <br />r <br />se <br />?. or than passem dimity reipordbir for gathering the Infonnatioo. the Inforrnalion <br />subinllied I& to the Dent of my knowledge and belief. Irv*. emirate. and romplete. <br />t then are si <br />nificant <br />lti <br />for rubmillin <br />fate Inrorrnatl <br />SIGNATURE Of PRINCIPAL EXECUTNT <br />I a <br />awar <br />n <br />th <br />I <br />TYPED OR PRWTED g <br />pe <br />m <br />a <br />a <br />es <br />g <br />on. <br />e <br />Inchding the possibility of fine and ImpAfwtaent for knowing .idaWed. OFFICER OR AUTHORIZED AGENT AREA <br />CODE HUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS IReferenc• sN attachments hare) <br />!-°P"Fl'•: i i,:?GT? <br />,j PF=t^Tp cVFeNT , c C I ??Ii1ry. TF CL ATM <br />EPA Form 3320-1 ?Rev 3'991 Previous editions may be used This IS a A-part fonn PAGE OF