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PERMITTEE NAME/ADDRESS ilnrlude Farifin %amellwearinlt ifDifferear <br />NAME <br />ADDRESS <br />-IF: R us 9 <br />FACILITY <br />LOCATION R US _i 6 <br />'d REDE'I VII flii.NE `NGINEEF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approve,' <br />OME No 2040 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ;. , . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE % <br /> MEASUREMENT ' <br /> PERMIT <br />l <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ?. <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif. ,..d,-r p mdt+ of la.+ that Ihi, d..rnment and au allachmenl, wet.` <br />prr•purrd utlrler m? dini tion or ,ulk'n i,ion in ari'onldncc eilh a ,,,Trot dr,iLnrtl TELEPHONE DATE <br /> 1 -more lhul .I"Air-1 IM' pnnl'I Prop-H. L'lllller alnl l":IIWIC thI Inf..flliall.gl <br /> <br />e <br />,ubmitl,d. It;t,rd un my inyutry or the Iw nnu ..r 1,,,-,n, , h.. nl.utagr the ,},lem. / <br />- <br /> ur thna Ixnon+ direclh re+pm,ihle I- gel hrrmg Ih, inf.a mulnrn. the mfurmahnn <br />, ~' <br /> ,uhmilled u. lu Ihr I>,.1 ..f m. l.nn+.ledpc and Ixhrf, true arr -rule. and cnmPlMC. "' _- - <br />~ - - /, <br /> I um a+. arr th <br />n Ihrrr arr ,igmfie:utl <br />rnalhr, for ,ubmium;; ral,c ml..rrnAlion SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />TYPED OR PRINTED . <br />p <br />. <br />in, I I • Ihr 1" ^i1,di1.. J` fin.' and p <br />.m r1,.nunrnl f- An....in_, -d t I i <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />IP E <br />1- <br />BURDEN OF PROOF REGUIRE11EN1 <br />IN 4C t'O(.1PS: <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used Thl,, 1N a 4-parf forni. PAGE OF