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PERMITTEE NAME/ADDRESS (7n.&& ft-asyMoo?Lorarsan (1D(06mm) <br />NAME <br />ADDRESS IVU. <br />FACILITY 1 (j <br />LOCATION _R CIE-r <br />T l- t <br />It T'A;-y. P=r F-S T?')r 1V i <br />NATIONAL POLLUTANT DISCHARGE EUMINAnoN SYSTEM /NPOESI <br />DISCHARGE MONITORING REPORT /OMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved, <br />OMB No 2040-0004 <br />NOTE: Read IrMtructlone before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCr <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT #t : l , <br /> REQUIREMENT } x i NUT. <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />#? <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT { ?`# k #tE### <br /> REQUIREMENT I~lA %• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , U(' iii' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT PORT <br /> REQUIREMENT i3-r MAX <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />PRINCIPAL EXECUTIVE OFFICER t "r"ly and" pen. y ° I- that thisdonrmem and oil attachments wen TELEPHONE <br />nT DATE <br />LE <br />prepared under my direcllon or .upervWc n In aceordsn with • system designed <br />NAMEf <br />to assure that qualified personnel properly gather and evaluate the Inrormatlon <br />submitted. Based on my Inquiry d the person or person who manage the system, <br />- <br />or those persons dlrMly responsible for gathering the Informatlon, the Information <br />submitted b, to the bat of my knowledge and belief, true, accurale• and complete. <br />F PRINCIPA <br />EXECUTIVE <br />NA <br /> 1 am .wan that there are sigrsincant penalties for abrrdlting robe Inrorr atkm. SIG <br />TURE O <br />L AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED Including the possibility of floe and Imprbet. ment for knowing AoIsUons. OFFICER OR AUTHORIZED AGENT CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference &N attachments herel <br />T -;rI r°.,? F nnI_T-•,C t_TMTT tir1it;€? ,-rp "_>1.OYR. <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-pert forin PAGE OF