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PERMITTEE NAME/ADDRESS ilnrlndr Faciliq lamdl.Iralian if Aijfrrenl <br />NAME <br />ADDRESS ` <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />OMB No. 2040-0004' <br />NOTE: Read Instructions before comoletina this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> EX 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 L <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT t 1 <br /> PERMIT l - <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 1 <br /> REQUIREMENT '• J <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eerbr% under fw•Indth -n hn. that the, drw'urn-1 and all utluchment, awra' <br />ale I under nn drr <br />e <br />tn <br />d <br />i <br />i <br />h TELEPHONE DATE <br />!- <br />?.! - : ?' ?! ;" . , ._• ?? `,/. r •. pl <br />p <br />.v <br />m tr -[-r +pnl <br />n arrnr <br />ancr w <br />.1 ,a,h•m de,ipned <br />t <br />In :I,wre That yualirwd fie-nnel p-bier-1, "ther and e,:dtnlle the infurmuti„n <br /> ,uhm it led. 1laerd un nq inquire of the lie-ii or lw -n% who manage the, %ten'. <br />- <br /> ur III- IK r,un, dm-ctk re,pun,ihle L,r eatheriug the inbinnaimn. the infurln.bon ! <br />" -. <br /> -knitted i,. to the lw,t of nn hit-- rage and belief. <br />true. accurate. and cnnlldrlr, <br />- i . <br />. <br />I ` i <br /> I .nu a"are that there an- ignincan {w•nalhe, lor,id-itting t.dv inbv awn SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />itwhidmg the {?," p Ibilm or rne and int n,,,1 1 ment r- in <br />6n• % 1.0-i- <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />ODE <br />YEAR <br />MO <br />DAY <br />%,UIVIIVICI\ I J /i1YV CAVLH1YN I IUIV Ur MIN I V IULN I IUI`IJ (r7C 1 W WRore dIl dlldl: <br />EPA Form 3320.1 (Rev 3.!99) Previous editions may be used- <br />nere/ <br />:. EVENT SUi•JECT TO BURDEN OF PROGF PEOUIRi <br />rF-iE: i]TVISEON WITHIN 48 'r-JURO. <br />- - This is a 4-pert f6rm.