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PERMITTEE NAME/ADDRESS (7-" FrfBlyNdw?Lorsnaw 1fD(fD t) NATIONAL POLLUTANT OISCHAAOE ELIMINATION SYSTEM //NPDES/ Form Approved <br />NAME DISCHARGE MONITORING REPORT WMRI OMB No 2040-0004 <br />ADDRESS <br />I PERMIT NUMBER DISCHMIGE NUMBER <br />MONITORING PERIOD <br />FACILITY - <br />LOCATION Kt FROM YEAR M DAY TO YEAR MO DAY <br />I-I- NOTE: Read Ifwtructlorw boforo completing this form. <br />Lit li L- I PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• 1FREOLIE"CY SAMPLE <br /> <br /> <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT -- <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />NAfyA /TITLE PRINCIPAL EX?CUTTVE OFFICER 1 renrty u r pent, ty o Isw that thh dorument rand ?1 sit-hments were <br /> <br />prepared under my di-11- or mperelslon In accord- with • system darned <br />to Aare that quahnrd personnel properly gather and eealuatt the Inform soon <br />/ <br />?- / <br />/ <br />10 <br />'• <br />TELEPHONE <br />DATE <br /> submitted Based on my Inquiry of the person or persons who mana <br />trm <br />e the 4 <br />- -? C ._ <br />- i/' <br /> <br />- sys <br />g <br />. <br />nr those persons directly responsible for gathering the Intern atlon, the Informati n <br />` <br /> <br />- / ' ,/ <br /> <br />t <br /> submitted b, to the bat of my knowledge and WWI <br />, trot, aceorste, and comptrir. t r .. •J (? <br /> 1 am aware that then are A(Necsnt penalties for mbmllting rate Information SIGNATURE OF ?RINCWAL EXEC r" <br />TYPED OR PRINTED , <br />Including fife poselblety or fine and Imprlsrmrnent for knowing etdatiorss OFFICER OR AUTHORIZED AGENT cooE HUMBLER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reference a# attachments there/ <br />??R PRE` EYFINT IS Ci AIMED ? c Cl_AT"- APPROV!-r <br />:TR[ - <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is 8 4=part foinn. #AGE OF