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PERMITTEE NAME/ADDRESS (Include Fardhc hSmu--IL ?anun rf brflin•nu NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form AppMved' <br />NAME <br />r I.l r; DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />ADDRESS 1 .:_._' - _ l ty [ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />NOTE- Rpari Ingtnlrtinnc hPfora rmmnlntinn thic form <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX ANALYSIS TYPE <br /> SAMPLE ; •:y ; <br /> MEASUREMENT J <br />U <br /> i <br /> PERMIT REP0 P i= .i #tr# sx ii i- R t-' ## r t F, <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?•TITLE PRINCIPAL EXECUTIVE OFFICER I ccnlfq under penaltc of law that tins dot umem and all un ch:nent. were TELEPHONE DATE <br /> prepared under my ditccuon or ,upenision in aecord:uuc with a system deigned <br /> to assure that qualified persanncl properh gather and evaluate the niformation f <br /> submitted (Based on my inquiryof the perwn or persons who manage the sy,tent ` <br /> or rho- persons directly responsible for gathering the infomtauon. the inl'ormaticm - <br />, I r <br /> submitted t,. to the best of m,t know ledgc and tube(, true, accurate, and cumplcte. <br />I SIGN URE OF PRINCIPAL EXECUTIVE J f S <br /> am aware chat there arc significant penalnes for iuhimmng false information. <br /> <br />TYPED OR PRINTED <br />n eluding thr of-ibilm of tin,- and amprienmrcnt lire knowing stolanons. OF CER OR AUTHORIZED AGENT AAEA <br />NUMBER <br />YEAR <br />MO <br /> <br />rrnRARAGAITC AWn GvDI AnIATlr%kl nC A.IV 1/Irl1 <br />ATir,\IC CODE DAY <br />Er r' FRELIf= EVENT SU B,-IECT 10 BURDEN OF PROC.-F RE(.UIREIEN1 <br />a . < . --D TC; THE D I V I S I r)N WI TH T N 4H t +il' 107. <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 0206 This-i3,1 4-part form.