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// Form Approved <br />PfRMITTEE NAME/Al)' SS /7-4-A+Fec+ttr" ^^^ t NATIONAL D POLLUTANT POESI OMB No 2040-0004 <br />MONITORING REPORT (OMR) <br />NAME <br />yt <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD - - - - - - - - <br />FACILITY YEAR MO DAY YEAR MO DAY G i ; J <br />LOCATION FROM TO <br />NOTE: Read Ifwtruetiof» beltxt? eompllltinp thh form' <br /> QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. <br />rRIOUENCY <br />SAMPLE <br />PARAMETER EX NALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS A <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />AEOUIREMENT <br />NAMEfnTLE PRINCIPAL EXECUTIVE OFFICER t few Iy " ` pe"a'y " low that this dontmenl and all marhmertu were TELEPHONE <br />prepared under my dlrectfon or supe-felon In a rdar with a system deigned DATE <br />j to amum that quaMned personnel properly gather and evaluate the Information <br />Based on my inquiry of the person or persons who manage the system. <br />_ - I <br />i , submitted <br />- <br />_ - <br />. <br />ar those prnoro directly respoitsible foe gathering the Information, the InfornsaMon <br />subadued Is, to the best of my km-ledge and belief, truc accurate. and complete. <br />EC <br />/ <br />/ <br />' <br /> I am aware out there are significant penaltle ror submitting False Information, UTT <br />SIGNATURE OF ?RINCMAI EX <br />E AREA <br />M <br /> rlalaUom <br />nd Im <br />isonment for knowin <br />r fi <br />e <br />ilit OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR O DAY <br />TYPED OR PRINTED pr <br />g <br />y o <br />n <br />a <br />Including the possib <br />^P,?f fAF?y7$ -AND EXPLANATION OF ANY VIULAIIVNb Irrornrancar err aIttl4+++rrw+++?++w+w+ <br />--- This is a 4-pan (?n:: PACE of <br />EPA > orm 33?0-1 f0ev 3'991 Previous edt?ons may be used