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PERMITTEE NAME/ADDRESS d lr.Jr F.6hri Aame L can" ifDiffr xmU <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 MO DAY <br />FROM TO <br />PARAMETER QUANTITY OR LOADING <br />CONCENTRATION NO, FREQUENCY SAM <br />QUALITY OR CON <br /> <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I c ht,ty undr Ixna1R ,,t la. that this docunxm and all anachmnns %ere TELEPHONE DATE <br /> prepared under my dsn.•rti,m ,,r Supen ISUm in asordance with a ynem designed <br /> ;...tswre that yttahfied perwrinel pi-,perk gather and evaluate the tntormation _-?- <br />- - - <br />?? G= ;ubmincd Based on my ntgwr} of the per'xm or permm> who manage the wsum, -Y <br />L2 or those persona directly respmtsmle for gathering Ilse information. the inf rrmahon <br />-? <br />- ;uhnutted is. I. the beu of my knowledge and !chef. true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I atn awarr that thcrr arc stgmticant penalties for submitting false information. O IG OR THORIZED AGENT <br />PLE <br />A " <br />l TYPED OR PRINTED m, !,J,110 1111 l4»-161!111 11 r,c sad :n:pri mn cm Tor kw-rnu oiolailons FF ER AU CODE NUMBER EAR M DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />EX OF TYPE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form. PAGE OF