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PERMITTEE NAME/ADDRESS,Lrcludc Facdin ti:w;? L, wiw: d Ihlir?r,ur NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />NAME DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER ('i)JL <br />MONITORING PERIOD WA191-1 <br />FACIUTY <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO /( J <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX 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 ;< r > - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />"I 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 certmy under penalty of law that this documrnt and all attachments were TELEPHONE DATE <br /> prepared under ms drrection or Supenvrsum in accordance with a system designed <br />t' t <br />S! G ' I C to assure that yu:ditied pcmnucl properly gather and ecakwte the mtormauon <br />h <br />i <br />f <br />h <br />=- -- - <br /> e petu,n or person, who manage t <br />e sy1tcm. <br />uhnutt Based on my <br />nquiry o <br />t - <br />`7 <br />" <br />- <br /> or those persons directly responsible for fathering the inf,mtation. the Information <br />= <br />-- - <br />- ?- <br />5 t <br />d <br />l <br />b <br />th <br />h <br />t <br />f <br />k <br />l <br />d <br />d b <br />li <br />f <br />A l rue. acauratc. an <br />comp <br />ete <br />mtttcd IS. to <br />e, <br />o <br />my <br />now <br />e <br />ge an <br />e <br />e <br />, <br />su <br />e <br />iti <br />t <br />lt <br />b <br />tt <br />b <br />to <br />+e: <br />h <br />t th <br />f <br />1 <br />I SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED -OR PRINTED ere arc ,Ifm <br />pena <br />ies <br />or Su <br />ing <br />c n <br />n <br />n. <br />am aware t <br />a <br />can <br />mi <br />"0 <br />mcludmg the p+-ththt} + t tine and unpri onment for know in. . i•"Lu:, "` OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />I:UMMtN15 ANU tAFLANAI WN Ur A147 VIULAI IUIYA trrerererrGe drr dlldGl7r <br />11wel <br />!?UL <br />This Form 3320.1 (Rev. 3/99) Previous editions may be used. This tS_3 4-part YOnll.