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PEA11AITTEE NAME/ADOFIESS(t--"F.ewry Nas-IL-wlan((D(Q'"t) <br />NAME <br />ADDRESS <br />Attq( <br />FACILITY WYO <br />LOCATION ER <br />NATIONAL POLLUTANT 04SCHAAGE ELIMINATION SYSTEM (/NPDE.4) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHAfiGE NLUaeE1111 <br />MONITORING PERIOD <br />YEAR MO DAY YEA MID, DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />If•>t* NO DISCHARGE <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> eF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ` <br /> MEASUREMENT <br />t ! - PERMIT <br /> REQUIREMENT M I P? I <br />_ SAMPLE _ <br /> MEASUREMENT <br /> <br /> PERMIT <br />N .1 l! <br />- REQUIREMENT A i7)a I Y t" <br />- SAMPLE -- --- <br /> MEASUREMENT <br />- <br /> PERMIT <br /> REQUIREMENT ?l?[!ll riti!I mil;-t I r ? <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />.. i REQUIREMENT - i .-: <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT s <br /> <br />t, REQUIREMENT I?fSI t 1:`-1,• <br />11 _fi <br />t _ SAMPLE <br />T!?EATNE,N T .. MEASUREMENT <br />' 6 <br />) <br />C. <br />- <br />PERMIT 1. 1 <br />1! - P.- Be 0, 01 is Ill 11 <br />=R09S Vr L REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NA ?MTLE PRINCIPA EXECUTIVE OFFICER t re^'ty ° «pen¦ i o b+ Choi UH docsrmenl and all .11-h-(, sere <br />TELEPHONE <br />DATE <br /> prepared under my dlrec Clod or wpervtalon In accordann with a system dalgned , <br /> <br />' In aw,.- that g.aNnad pertonnel property gather and e•stuate the Infnrmatlort <br />• <br />1 , • wbmttled. Dowd on my lnaul y of the perwn or pemoeu who manage the system, <br />or Chase persona directly resporalble for gathering the Information, the Infarmatlon <br />r <br />i <br />7 <br />? <br /> wbmttud h, to the bat of my kno+tedgt and Denies. Crw. a mte, and complete 1 <br /> I am aware that then are significant penal" for wbmlttin <br />raise inf <br />r <br />tl X <br />SIGNATURE OF irRING'IrAI EXECUTIVE <br />TYPED OR PRINTED g <br />mat <br />o <br />on. <br />Irk-f ding the pasdbttlly of floe and Imprisonment ror kno.ing .Iol.tJom, OFFICER OR AUTHORIZEO AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference sd •ttechments here) <br />R PnE(^?:- EVENT T':! <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used TTIIS iS a 4-part form. PAGE OF