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P£RMITTEE NAME/ADDRESSt1wrM6FacabrN0-WL-lonVV06 0 <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM JNPDE.S/ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER OISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMs No 2040-0004 <br />yrs./+.=•--? :, - : d _ :- -?' ?'-- ?. <br />NOTE: Read kntructlone baforlie completing thle form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY <br />OF SAMPLE <br /> EX 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 /> 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 /> SAMPLE <br /> MEASUREMENT <br />PERMIT f <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ' fe^"> ° er pena ry o Iaw IMI ihh document and all aitschmerttswere TELEPHONE <br />er?Ifl <br />m In a <br />ce with a s <br />stem desi <br />ned <br />n <br />r <br />rd <br />d <br />d <br />i <br />i DATE <br />y <br />g <br />sup <br />r <br />cco <br />an <br />un <br />er me d <br />rect <br />o <br />o <br />Prepare <br />r to enure that quohned pe-nef properly gather and evaluate the Information <br />uir <br />of the <br />erson or <br />ersons who mana <br />e the s <br />stem <br />b <br />itted <br />a <br />d <br />n m <br />In <br />y <br />p <br />p <br />g <br />y <br />, <br />su <br />. <br />war <br />o <br />y <br />q <br />m <br />or those perame directly responnlble for gathering the information, the Information <br />wbmltted h, to the best of my knowledre and belle(, true, accurate. and complete. <br />IGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that then are sleeninont penaltl s ror wbmltting false Infonmuon, S A A <br />TYPED OR PRINTED Including the possibility of floe and Imprisonment for knowing violations, OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments heral <br />EPA Form 3320-1 (Rev 3!991 Previous editions may be used This is a 4-part form- PAGE OF