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PERMITTEE NAMEIADDRESS (7.evr FwikryNrrrLeeo„on I(DIQItewu) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM //NPDESI <br />NAME DISCHARGE MONITORING REPORT IDMRI <br />ADDRESS <br />jjpk 4?.' PERMIT NUMBER DISCHARGE NUMBER <br />-IN I A MONITORING PERIOD <br />FACIIrTY 1 - <br />I E ?G. c i'1 f : YEAR MO DAY YEAR MO DAY <br />LOCATION ',N I A FROM TO <br />i LL i AM A. B EA,r <br />Foam Approved <br />OMB No 2040-0004 <br />c,UC4 ;t <br />F - FINAL DELTA <br />SR, DETER TRL DTC OR UNP7P Tft i E <br />NOTE: Reed Instructlorne before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FRIOU <br />NCY SAMPLE I <br /> F <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - ?. L - <br />l REQUIREMENT <br />!''iii X 11"11: ..•. <br /> SAMPLE <br />C E1'. _ MEASUREMENT <br />O 1 PERMIT # ## # i;7 - r..' <br />I_)EN•i VA' REQUIREMENT DA i LY Mx 1`1UNTH <br /> SAMPLE <br /> MEASUREMENT <br />C1 ?i <br />PERMIT x###n fi .. ?# r#; (' r REPORT - <br /> <br />H.? <br /> REQUIREMENT ''?DE, DAILY MX MONTH <br />?L SAMPLE u <br />FF-. MEASUREMENT <br /> PERMIT r- <br />JT REQUIREMENT 30DCi _Y '-rH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r .w##r: r-,: Q st.•.- # is #tr 1 "n , v <br />7777- <br /> REQUIREMENT !ST MAX GEr <br /> SAMPLE iit .i ,. .. <br />1 MEASUREMENT <br />i PERMIT REP OP 'E:PRT _ <br />I T\1 6: 1 ; <br />=NT GF r V,AL REQUIREMENT 3t Dr, r' > F L , ' r' <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />r f`I% a <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER ' -My " nder P•n•'y o .. that th6 docomaol and all allwitmentr nen <br />TELEPHONE <br />d <br />f <br />DATE <br />prepare <br />armor my elrecuon or wperrg <br />ow In ercord.nee with . syetem eesigrrd <br /> to mart that qualified personnel properly gather and eyatuate the Inform.llon - <br /> wnbmltled. eased on my Inquiry of the person or persona who manate the lyrtem. <br /> or Ihou persona directly mpondbie for gathering the Information, the Infornrtlon - <br /> wbmflled l% b the bat of my knowledge and b.*ef. ime• a rale, and complete. <br /> <br />I am aware that then an significant penallla ror wbmtlnng faire Infonn.tlen <br />fIONATURE OF ?RINCfPAL EXECUTIVE / <br />TYPED OR PRINTED , <br />Including the possibility of fine and Impri.atment roc knowing yldatlorei OFFICER OR AUTHORIZED AGENT <br />AAEA 00E NUMBER <br />C <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EAMANA 1 tutr ur Ayr T V IVILA I IVNa Irfererence off erracnmenrs nere/ <br />C1aA G?R17,- n, IT Tc r L,jMED Tr- (iL.!,I ScrP?(lt!cr r: <br />EPA Form 3320-1 (Rev 3/99) Previous editions may be used This is a 4-part form. PAGE OF