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PERMITTEE NAME/ADDRESS (/ne" Fat+BryNwalt"onou 11DIQ6.wn.9 <br />NAME <br />ADDRESS 7W Y O NINE <br />i SYr'+l"F 1-IICHW <br />FACILITY lJ !? F r <br />LOCATION _ <br />Ci ;aANI))=fi <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (WDES/ <br />DISCHARGE MONITORING REPORT (O R) <br />PERMIT NUMBER 04SCHARGE NUMBER <br />MONITORING PERIOD <br />YEA MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read k»tructiorte before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, rREOUENCr <br />of SAMPLE <br /> EX TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE ' <br /> MEASUREMENT <br /> <br /> PERMIT :• <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ) <br /> <br /> PERMIT <br />- REQUIREMENT <br /> SAMPLE ! I <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />tISiF MEASUREMENT <br /> <br /> PERMIT L <br /> REQUIREMENT <br /> SAMPLE I / <br /> MEASUREMENT f?J <br /> <br />r;. PERMIT <br />'• REQUIREMENT <br /> SAMPLE N'1 n/ <br />n <br />-" MEASUREMENT ? <br /> PERMIT _ 1 NI-ST PAX' <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NCIPAL EXECUTIVE OFFICER t ce- ° r pens y o L Iha th is docatnent and .11 •tl¦rnenenu wart <br />lth <br />t <br />d TELEPHONE DATE <br />NAME/T1TLE PRI a sys <br />em designe <br />prepared under my dlrmflon or wlser.yan In tweord¦nce w '?• <br /> to assum that qualffled personnel properly gather and es•lu¦le the Infetrvullon <br />e nnn or <br />ersons who manage ese s <br />stem <br />ui <br />d <br />m <br />In <br />of th <br />l <br />d <br />B -. " _f <br />.: <br /> . <br />q <br />ry <br />e p <br />y <br />on <br />y <br />p <br />fubmit <br />e <br />. <br />oar <br />or, hose persons directly -P--,Ibk for [.1h,-& the Inforrrullon. the Information • <br />; _ <br /> W and <br />m <br />l <br />b <br />,y t :r ?v - •! / co <br />pi <br />e a. <br />nt of my ?newkdge and lxtlef. true. ae - <br />mbmllted K to the <br />OF IRINCI?A <br />EXE CI?TIVE <br />- <br />/ <br />_ <br />V / 1 1 am aware that then are siEniflrant penalties for submlitln9 M1tsr Inromssbn, SIGNATURE <br />L <br />O <br />GENT <br />AUTHORIZE A WA <br />NUMtgER YEAR MO DAY <br />TYPED OR PRINTED Inetudin? tl+r pesadbllity or Ilse and imprtsettment for knowing e1M.uoru R <br />D A <br />OFFICER CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference 0attechmentsherel ;R pREOIP E?yF4v? <br />? %S CLAZMET: L CLAI:Y ;7?R(3Vt^ <br />P'T W(3CI i, <br /> c , •, ri _ <br />REIN' <br /> <br /> <br /> ?• This is a 1 rears form Auc OF <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used.