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PERMITTEE NAME/ADDRESS parcbi.F-tkiylvsu.dLa wi-(/O(ff ? t) NATIONAL POLLUTANT OISCHARGE ELIMINATION SN i EM Ib'F'u[ Approved <br />NAME DISCHARGE MONITORING REPORT IDMRI 3%15 No 2040-0004 <br />ADDRESS It i ., ; <br />_l Jam', I_ - t iI'4AL _ <br />_ PERMIT NUMBER ascHAROENUMBER r,Cl„t T) . T; c: C, C ;? <br />KE <br />.C.JYCi MIN.r <br />FACILITY MONITORING PERIOD <br />YEAR ..M AY [?? MO D J'`? <br />IpCAT10N i?5, ?.7R J` FROM - TO V <br />NOTE: Rand Irrtructlom before r_oalelatlno thla form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUFNCY SAMPI- <br /> O <br />OF <br /> EX AN TYPE <br /> AVERAGE-: MAXIMUM UNITS MINIMUM. ..' AVERAGE = MAXIMUM UNITS <br />1 <br /> <br />SAMPLE -_ - <br /> MEASUREMENT <br />t:' PERMIT i MAX i,. ' - - - ----- . <br /> REQUIREMENT h <br />j <br /> SAMPLE _ -- <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - - - -- <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />1 SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br />- REQUIREMENT <br />- <br />- - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />- ----- <br /> PERMIT <br /> AEQUIREMENT <br />NAM /TITLE PRINCI L EXECUTIVE OFFICER I "rstq under <br />D•"' ty ?'" that fhb d xvm,nt anti .ii .n.rhn+ente woe <br /> <br />• <br /> <br />TELEPHONE <br /> <br />DATE <br /> prep.red.w„ my direetlnn or suprr.lslon In aeeoed."" with a system delta.., J <br />. <br />/ to arum that Ru.11Md Personnel property [.then and e,sh sle the I.I ra allon <br />submitted. Bred on my Inquiry, o/ the Person or Persons who manse the s_ntem. - <br />- <br />- _ ?i - <br />' <br /> <br />' <br />?/f <br />? <br />' • <br />•? or those persons directly responslble for gathering the inform.tlon• the Infornrtlon / - <br />- - <br />i ( ,- { <br />?/' <br />; <br />, submitted ht, to the bet of my knowledge and better. true. a-irate. and complete <br /> 1 am swan that there art significant Pen.ltla for n,h,.iltint rate, lnfnrwtatlon SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />loel.ding the poadbmly or fine and Imprisonment for tnowlng,W.tior OFFICER OR AUTHORIZED AGENT CODE NLIMflER YEAR MO DAY <br />COMMENIS ANU tAVLJgnnltUM yr fins v9wL,^wrvP1, lrriraronca all arfaVJ7M*Rrl final r t•._? ai C4 Giv L- r" It #E-J. _ vs_r?s. t r-rrr;(+ wtsvLA <br />r?l` aI???7tw i ratf*tOlt, rtQM!=, - r. C. <br />F1( <br />EPA Form 3320-1 (Rev- 3199) Previous editions may be used This is a 4-part Corm.