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PERMITTEE NAME/ADDRESS flndud: Iacilac Vdrn, l.,rou.,n if 1),fl,nnti NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />F 7[- <br />Form Approved. <br />OMB No 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />ICI <br /> MEASUREMENT <br /> PERMIT <br /> ~ <br /> REQUIREMENT <br /> SAMPLE <br />N <br />t <br />`t <br /> MEASUREMENT <br /> <br /> PERMIT " <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br />r4 <br />" <br /> MEASUREMENT - <br /> } <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />,,,? <br />,t'? r? <br />CS>?r <br />I <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> x" <br /> PERMIT t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />AME/TITLE PRINCIPAL EXECUTIVE OFFICER t certif. under Ix-nalh of I:,.• dt,d thi+dex-ument and all adtachmentn %err t TELEPHONE DATE <br />N prrpamd under me direeti..n or +uper%icion in uv urdum?c W ith a system de.it;ned <br />_ <br />- - <br />"J <br />" to assure that yualirtrd pen,,nud properh gather and eraluate the inrormation <br />t <br />h <br />h <br />- <br />- <br />- - - em. <br />o manage t <br />e •)s <br />submitted. Hasid on m-v inyi, %..( the Prrsnn or person. w <br />ersons directh re•I*msible for gathering the informatkm, the information <br />or Ili- <br /> p <br />+uhmilled is. to the 1-1 4 rn. t.nowiedge end belier. true, accurate, and -niplete_ SIGNATURE OF PRINCIPAL EXECUTIVE I Jt - <br /> I am aware that therr are s-,nificint Penalties ror submitting rake information. D AGENT <br />R <br />U <br />H <br />R <br />Z AREA <br />R <br />MO <br />TYPED OR PRINTED ncluding the pessibilih of tuu and imprisonment fur knowing siolutiom. OFFICER O <br />A <br />T <br />O <br />I <br />E DE NUMBER YEA DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA I ILIN5 (Hererence an arTacnmenfs nerej <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used, I-hIS Is d 4-hart I t ten