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PERMITTEE NAME/ADDRESS llnclude Farifily Name / ni,Y. n ,J fh/J.r.nf NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No 2040-0044 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />II° <br />I <br />I,? <br />t`4SlT? <br /> MEASUREMENT <br /> PERMIT -- <br /> REQUIREMENT <br /> SAMPLE , , <br /> <br />` <br /> <br />f <br />3 <br />t <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT " -' <br /> SAMPLE <br />LI <br />?j <br />C 4 .p. <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ; <br />" <br />`Y l1) <br />( ,k?'?? <br /> MEASUREMENT <br /> PERMIT _ ' <br /> REQUIREMENT <br /> SAMPLE _ r <br />41 <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />A <br />M <br /> ME <br />SURE <br />ENT . <br /> PERMIT <br /> REQUIREMENT i <br /> SAMPLE < ?l <br />{J I / <br />`II '` `? <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT I <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify ender petudtt of law that this document and all attachment%were <br />-d <br />t di <br />li <br />r <br />u <br />- W <br />i <br />cc <br />rda <br />ith <br />. <br />t <br />de <br />i <br />n <br />d <br />d Y TELEPHONE DATE <br />> prepan <br />tin <br />er m <br />on o <br />. <br />l <br />on <br />n A <br />o <br />nce w <br />a <br />L <br />rm <br />s <br />g <br />e <br />- <br />- <br />ather <br />d rral <br />tio <br />- <br />A <br />t <br />that <br />alifi <br />er- <br />ael <br />rh <br />lr the i <br />form <br />d <br />?s J ` 1) f , c <br />L 1 <br />l <br />on <br />qu <br />p <br />n <br />p <br />pe <br />an <br />uu <br />a <br />n <br />e <br />n <br />g <br />- <br />` 'uhmiu<d. Razed on m? inquire of the person or persons who manage the gstem, 1 - <br /> <br /> <br />, or Ih,ne pcr,ons direeU) rc,pon%ihh- fur gathering the information, the information <br />? <br />' <br />• <br />? submitted is <br />to the hest a my WH-Irdgr And belief <br />true <br />nccurale <br />and complete. <' <br />4 v <br />' <br />' <br />' <br />- ? <br />_ <br />' - - , <br />. <br />, <br />, <br />i <br />f <br />f <br />l <br />i <br />i SIGNATURE OF PRINCIPAL EXECUTIVE , <br />?. <br />- <br /> <br /> <br />TYPED OR PRINTED <br />nforntat <br />I am Awure that there:or s <br />icant penalties for+nhmitting <br />a <br />se <br />,m. <br />gni <br />ncluding the pon,ihitith nr fine Aud imprisonment for knowing siotatbns. <br />OFFICER OR AUTHORIZED AGENT <br />AREA BER <br />NUM <br />O <br />D <br />C <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form x320-1 (Rev. 3199) Previous editions may be used. 'nik is a 4-part form. PAGE OF