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PERMITTEE NAMEIADDRE55p.rvdrse??rrM.+rt«..re+?l/?I?+MI <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (INPDESI <br />DISCHARGE MONITORING REPORT IDMRI <br />PERMIT NUMBER DISCHARGE NLIMBER <br />MONITORING PERIOD <br />YEAR MO DAY Y MO DAY <br />FROM t TO I <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read kietructione beitforo completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br />raIEOOUFNCr <br />SAMPLE <br /> EX <br />EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i6l % <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT u - X <br /> <br />T.*" SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/T1TLE PRINCIPAL EXECUTIVE OFFICER ' "flay r r Pena ty o law that thlr deevmemt and ail ¦ttacfitnenL, were TELEPHONE <br />prepared ender my dImetlon or sup.. +hlon In accordance whh ¦ sfstcm designed DATE <br />to care that geeNMd personnA property [ether and ... fuel, the Infnnnelbn <br />/ , t f r r submltted. Bred on my Inquiry -(the person or per who manage the srstem, <br />or thou persons directly responsible for gathering the Information, the Infornutloa <br />submilld Is, to the licit of m7 knowledge and bead. true. accurate. and complete. <br />SIONATURE OF PRINCIIAL EXECUTIVE <br />d <br />' fluRI pestaleles for submlltint War Information. <br />I am aware that there are sltr ARIA <br />TYPED OR PRINTED Including the possibility of fIW and Imprisonment ror knowing .Ialallorm OFFICER OR AUTHORIZED AGENT CODE NUMBER <br />YEAR <br />MO <br />DAY <br />f c'OMMENTS AND EXPLANATION OF ANY VIOLATIONS fReforencesNel'WhMentshorol 4HR PRECIP EVENT IS CL AIMEll It ul-A11'1 htr'rrcli`?:.ti !3Y iJts`l.Y]g <br />T ^ Ir'f ir1' T j r [.F' f jCt ^1 ?rl C' 1.1 'pPTpy <br />` EPA' orm 3320-1 (Rev 3'99) Previous editions may be used f This is a 4-part roan PAGE OF