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PERMIT ME NAMEJADDRESS t7nei.* FodkiyNeas?Loertew l/D(t w s) <br />NAME <br />ADDRESS <br />RSET C <br />FACILITY CIRN CIreK ec ELK CRK MI <br />LOCATION _RSE I <br />MES "f COOPER, EXEC V. F <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-OP04 <br /> <br />NOTE: Read instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />Y <br /> ANALrsls PE <br />T <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i-if# s: r "1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />1 !5 PERMIT ,: .,. .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 "F61, under penalty a Isw that I s document and aH ti-hiv nts were TELEPHONE DATE <br /> Prepared under my dlreclTon or supe rvision In accorxls n with a system designed <br /> to inure that quaHHed personnel properly Lather and eratuele the Information <br /> submitted. Bond on my Inquiry of the person or persons who manage the system, <br />- <br />F or those persons directly responsible for galhering the Information, the Informaltom <br /> submitted Is, to the best of my knowledge and beW. Itw, accvnle <br />and complete <br /> , <br />. <br />I am .ware that there are significant <br />enalties for submllHn <br />rube Information <br />SIGNATURE OF PRINCNAL EXECUTIVE <br />TYPED OR PRINTED p <br />g <br />, <br />Including The possibility of fine and Imprisonment for knowing rloletlom OFFICER OR AUTHORIZED AGENT REA <br />COOS HUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re%rsncs sit etbchments here) <br />-rI -t--, Fns -1 - r„- <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used. THIS is a 4-Part form. PAGE OF