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PERMITTEE NAME/AV---Is (7-"F OrtyY wLx.ii-Uore a N <br />T " <br /> <br />NAME A <br />IONAL POLLUTANT N- <br />DISCHARGE ',ROE ELIMINATION SYSTEM NPOES) <br />-ORING REPORT (DMR/ <br />ADDREss GpOOgQ 00! <br /> PERMIT NUMBER DISCHAA E NUMSEA <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DA Y YEAR MO DAY <br /> FROM TO <br /> _ NOTE: Read Instructions before compl*tinp this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOWIO- SAMPLE <br />E <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS £X or <br />nNALYSrs TYPE <br /> SAMPLE <br /> MEASUREMENT i7 <br />PnDEO <br />1 nl,L <br /> <br /> <br />Oi G lGraaj2 <br />0An <br /> <br />wbmllled. Seed tm m <br />or Ih- Pennru dlrwil- <br />wbmllled h, to the b- <br />IMudln? the P...d blYl? <br />SIGNATURE 11.d lher.. <br />SIGNATURE Of <br />TELEPHONE GATE <br />i , <br />10 $a5? 0?7 <br />AAE: <br />CODE NUMBER ---.IYEAFi IviC`•yY' <br />PA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-part form. PAGE