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PERMITTEE NAME/ADDRESS Nnc•6elc /•'ac,!rr !!; Jcozvtu <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUAUTY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />? OF <br />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 y , <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT F, <br />_ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT I-c nrl(" R??F'' 'F <br /> REQUIREMENT <br /> SAMPLE <br />- - MEASUREMENT <br /> PERMIT F P 94. z <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l eerif} under penalty of law that tht, do,un •nt and all uttuchmrnn weir TELEPHONE DATE <br /> d <br />d <br />d <br />t <br />i <br />i <br />i <br />d <br />i <br />h <br />d <br />d <br />t <br />1 <br />0? ion ,,r supen <br />on <br />ance w <br />prepare <br />un <br />er m? <br />irec <br />s <br />n accor <br />t <br />a system <br />estute <br />to assure that uahfied persttmtcl pr.par. Is g ; •ather and a%-aluatc the miormauon <br /> <br />_- <br /> <br />as s <br />submitted R <br />ed nn my inymnv of the person or persons who manage the syaem, <br /> <br />= <br />? <br /> or thou persons drrccily responsthle for uttering the into rmation the information 'a!+ <br />? <br />- <br />-- <br />-- <br /> <br />1c; i t- <br />. <br />submuicd ,s t„ the hest of my know iedge ,nd he lief. to ae..urna. and comploc <br />- <br />? 7 _ <br /> <br />r <br />. <br />. I am aware that there are significant penaltic nor -hm:nine tsi,i• ;;tt;,rn; <br />tti,m SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />_ <br />- - <br />TYPED OR PRINTED , <br />, <br />including tirc jx,ssththty of fine:mcf ;mpnsortn,c,i !ur .m.wn, .;,,I:u„ n. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> cooE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.