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PERMITTEE NAME/ADORESS (7-6. reeOty)V..?L«.tien t(D(6-nwtl <br />NAME <br />ADDRESS C OL_ OW , . r^. I NE <br />.7 -11 <br />ER c. <br />FACuTY JWY' 7 - <br />LOCATION '<'ER - <br />_L.Y 1.:. :1Af?M _.N : VP OF <br />G O NATIONAL POLLUTANT 04SCHAROE ELIMINATION SYSTEM INPDES1 <br />DISCHARGE MONITORING REPORT (OMR) <br />1t \? 2 ' `"009 PERMIT NUMBER aSCHAROE NUMBER <br />p?v15% of a?dSae MONITORING PERIOD <br />j,p6m(i YEAR MO DAY YEAR O DAY <br />FROM TO <br />C l 1 Form Approved <br />OMB No 2040.0004 <br />NOTE: Read IrNtructlone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <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 />REQUIREMENT <br />' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />-- <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT L..? r ._ •r <br /> REQUIREMENT <br /> SAMPLE b <br /> MEASUREMENT <br />- PERMIT <br /> REQUIREMENT <br />t <br /> SAMPLE <br />- MEASUREMENT <br /> PERMIT <br />- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMERiTLE P NCIPAL EXECUTIVE OFFICER t far'"y under pens ty ° law the, Ihb d°r°me°t and an atn`h`wnt' -r- TELEPHONE <br />prepared under my direction or supervision In a rdenrr with a system deigned DATE <br />? 1 ,. to aaeurt that quanned personnel properly ether and tyahrtle the Infarmalbn <br />t r ' i ! submitted. Beard on my Inquiry *(the person or persons who menage the system, , -i <br />or those penor 0 directly m pondble for gathering the Informetl <br />on, the Information <br />submitted Is, to the bet of my knowledge and belief, trsr, a rate, end cornpkte. <br />NATURE OF <br />TIVE <br />SI <br />I <br /> I am aware that then are dgnincam penenles for submitting false Information, O <br />PR <br />NCIPPAL EXECU A EA <br />Y <br />TYPED OR PRINTED Including the poseiblitly of fine and Imprisonment For knowing vldaij r OFFICER OR AUTHORIZED AOENT CODE NUMBER YEAR MO DA <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Referancip aU attachments herel <br />'-4R PRECIP i- J CLAIMED. <br />' IF <br />ENT I ']V , <br />CLAIM A' ?D F3'{ >r3(3C0. <br /> . <br /> <br /> <br /> <br />')IIS 1S a 4-?yI form <br />1 <br />AGE OF <br />EPA Form 3320.1 (Rev 3/99) Previous editions may be used