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PERMITTEE NAME/ADDRESS (Include Facilio,Name/Location if Different)
<br />NAME
<br />ADDRESS ; •, i 3 l !I t) ('1 +'.% .
<br />FACILITY
<br />LOCATION 9 {
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT' (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR 4010 DAY
<br />FROM :•.t f. ,t, TO ..,>
<br />Form Approved.
<br />OMB No. 2040-0004
<br />NOTE- RParl Irintriuefinna hafnro rmmnlafinn fhic fnrm
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE
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<br />AVERAGE
<br />MAXIMUM
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were T ELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed j
<br />1 i , I t C:`[1 it a N lIl Sc -f l to assure that qualified personnel properly gather and evaluate the information
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<br />` submitted. Based on my inquiry of the person or persons who manage the system !
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<br />- submitted is, to the best of my knowledge and belief, true;, accurate, and complete. i
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE 23.
<br />338
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<br />, am aware t
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<br />ere are significant penalties for submitting false information,
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR IV80 DAY
<br />r`rRfiRAFNTG ANn FYOI AnIATInnI nF AKIV vlnl ATlnnlc ine+e.e,... ,u u a» .s w ,
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ,TI115+'lS,;a':4.-part:cfOYri1. PACE
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