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PERMITTEE NAMEIADDRESS(7emitseOyN...rterrio tfDfpb.nq <br />NAME <br />ADDRESS <br />_„ ...., <br />`IERSET C( <br />FACILITY :BORN CI','K & ELI,; CRK VIII, <br />( <br />LOCATION TERSE T C <br />1- !ES T COOPER. EXEC V. <br />NATIONAL POLLUTANT DiSCHAROE ELIMINATION SYSTEM (INPOES) <br />DISCHARGE MONITORING REPORT (DMRI <br />PERMIT NUMBER DISCHMGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0304 <br />R rip, ) <br />F- I NiAL <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> >< OF <br /> 1 EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - <br /> REQUIREMENT M1 X Z MU111 <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />I O <br /> PERMIT <br />RE <br />UIREMENT <br /> Q <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TtTLE PRINCIPAL EXECUTIVE OFFICER I mrtay under pen, ty o far. that this dcrume.t and all ¦uacAments were <br />TELEPHONE <br />DATE <br />prepared under me direction or supervlslon In attordanre with ¦ system designed <br />Io aa" that qualified personnel property gather and evaluate the Information <br />submitted. Bred on my Inquiry of the person or persons who manage the system, <br />or those perswa directly responslbk for gathering the Informa0o4 the Informed.. <br />submitted b. to the best of my it w " ge and belief, true, nevurNe, and complete. <br />I am $wart, the! !hart frs tlgnllican! penaitla roc fubmiltlng robe Informadim <br />SIGNATURE OF PRINCIPAL EXECUTNE <br />TYPED OR PRINTED . <br />Including the poasiblllty of flee and Imprisonment for knowing violations OFFICER OR AUTHORIZED AGENT CAREA <br />ODE NUMBER <br />YEAR <br />MO DAY <br />COMMENTS AND EXPLANA I IUN Ur AIrT VIVLA I IVNa I/feroronce an arracnmenrs nerol <br />EF <br />EPA Form 3320-1 (Rev- 3/99) Previous editions may be used <br />L. & GREASE- - SEE I B <br />This is a 4-part form.