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PERMITTEE NAME/ADDRESS r(nclukFurifir) .humeZn'ori n ijDu(jercrtll <br />NAME <br />ADDRESS L_ <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <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 />NOTE: Read Instructions before comnletina this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREDUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />,, •:.. MEASUREMENT <br /> PERMIT _t . <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 <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrtd under penalty of law that this document and all anachments were <br />di <br />d <br />d <br />t <br />i <br />d <br />d <br />d <br />i <br />h TELEPHONE DATE <br /> pr dare <br />un <br />ion or supcrv <br />er my <br />rec <br />ion in accor <br />ance w <br />t <br />a system <br />eigne <br />C061 <br />5f o 11 S / f eA to assure that qualified personnel properly gather and evaluate the mfannaunn r <br /> submitted. Based on my inymry of the perwn or pci-von, who manage the system. <br /> or these persons direct(} resporntble for gathering the information, the infor m I"" <br />L <br />G rt l lI f "t submits d is, to the best of mg knowledge and belief, true, accurate. and complete. <br />I wn aware that there arc significant penalties for submittin <br />false information SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPEDbR PRINTED g <br />, <br />including the possibthty of fine and imprisonment (or knowing v tolation` OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> CODE <br />GUMMtNIS ANU MAYLANAIIUN Ur ANT VIULAIIUNJ Irreverence an 8tI8Cnments nereJ <br />JR <br />r.. r <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. , I , This is a 4-Part total.