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PERMITTEE NAME/ADDRESS ,6o- l,rl. F.;. r,'„. <br />NAME <br />ADDRESS I rli <br />FACILITY <br />LOCATION <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 />t 0 ?1rm Approved. <br />OMB No. 2040-0004 <br />r <br />r <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 .. x ... ,. .)At <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 certtfl under penaln of law that this d,wument and all auachments were TELEPHONE DATE <br /> prepared under mq direction or supcrvsion to accordance with a system designed <br />r to assure that yualitied personnel propene gather and evuluatc the information <br />° -l - ' submitted B3 -%cd on my tnyuiry of the person of persons who ntanaec tite system, '- - <br /> (ir those person.. dirrol), responsible (x gathering the infnnuabnn. the information - '- 4 <br />_ <br />' submittal ts. to the best of my knowledge and belief. true, accurate, and complete <br />l <br />i <br />i <br />b <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE <br />- rmat <br />I am aware ttuit there arc significant penalt <br />-a for sv <br />mittmg <br />a <br />se int <br />on. <br />t f <br />s <br />ih <br />f ti <br />d <br />k <br />l <br />u <br />l <br />i <br />h OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED imprisonmen <br />or <br />nowing „o <br />ng t <br />e poss <br />dtn o <br />ne an <br />a <br />on <br />. <br />inc <br />ud CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />& GREASE REPO RI <br />EPA Form 3320-i (Rev. 3199) Previous editions may be used. ()OC,94, This ls,a 4-part form.