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PERMITTEE NAME/ADDRESS47neYft FaNkfyNnwdL cw'*w (MC06 0 NATIONAL POLLUTANT 04SCHAROE ELIMINATION SYSTEM_ JNPDES/ Form Approved <br />NAME DISCHARGE MONITORING REPORT (D R) OMB No. 2040-0004 <br />A DORE S S <br />PERMIT NUMBER OtSCHM40E NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY_ <br />NOTE: Read irvatructlone 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 /> <br /> PERMIT <br />; r.• :1 <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REOUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ', ,Id ) T MAX <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br />- PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEMTLE PRI CIPAL EXECUTIVE OFFICER I certhr under pen. ty o law that thh tocomenl and eat attachments here TELEPHONE <br />tion a w <br />ned <br />aRdhate <br />m <br />dl <br />„m desi <br />In d with a e DATE <br />g <br />tp <br />r <br />y <br />? <br />y <br />roprty <br />to <br />to afaure that quattfled Md personnel properly gather er and evahtale the Inlnrnutbn <br />sobmltted. eased on tar Inquiry of the parson or perwert who manage the system. <br />nr Moat per-n, dlrn,y respomibit for gathering the Inrormauon, the Inforneaoon <br />• <br /> <br />J <br />accontt <br />mbmllted b6 b the heft of my lwawledge and better <br />true <br />and complete <br />? <br />- -. <br />! <br />' <br />•E <br />!? <br />? <br />' . <br />. <br />. <br />. <br />. <br />j ! <br />, <br />- 7 <br />! <br />• <br />- <br />SIGNATURE OF PRINCIPAL EXECt1T1VE <br />i <br />I <br /> 1 am .- that there are s <br />gnificant penal"" for sobmltting 61st <br />nfoenrtbn. AAEA <br />TYPED OR PRINTED Including the powlblllty of Ilse and Imprltamment for Itm wing rlolatlotts OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rd rence aMancchmonf3 hired PRE(; 77f' EVENT TS- CLAIMED. IF CLAIM APPROV;: JO BY WGCD <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is 8 4-Pell form, PAGE OF