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PERMITTEE NAME/ADDRESS 170c&*F-OtYN--WL«r/an I(DOQk ,W) <br />NAME <br />ADDRESS <br />uJr- Lj <br />RSET Ci <br />FACILITY , O R N! C f K &: ELK C R I A , PSI I I <br />LOCATION F; SET C I <br />EE T- COOPER, EXEC V <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDESI <br />DISCHARGE MONITORING REPORT f0 Rl <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0104 <br />• '3 <br />NOTE: Read kletruedorle before completing We form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FtIEOUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - <br /> REQUIREMENT M T <br /> SAMPLE <br /> MEASUREMENT <br /> <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 /> 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 l fe't"y under peon -Ti--7` a law that this dotvmenl and all altachmtnts were <br />TELEPHONE <br />DATE <br />prepared coder my direction or supervision in accordance with • system designed <br />to assort that qusHfk4 personnel property gather and rsehaale the Information <br />submitted. Bred on my Inquiry of the penal or persons who manage the system, <br />or those persas directly respo"ble for gathering the Information, the Information <br />- submitted If, to the best of my knesekdte and belief, trut, arrurale, and complete. <br />I am aware that there are stgnln[sn! perWd" for sub rgtting W. In:r.: matWn <br />BIONATURE OF PRINCWAL EXECVTTVE ' <br />TYPED OR PRINTED . <br />Including the Possibility or flee and Imprisonment for knowing ,lolauorn <br />OFFICER OR AUTHORIZED AGENT A A <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS 1Reference eN atrechmenh here! -- <br />:r,t c ?r,l ?11 l MT c`Prt ?rn T-rlP <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used This IS a 4-Part fOfitl. PAGE OF