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PERMITTEENAME/ADDRESS (include Fatilih:1nmc+f..nemu:r/fh;b tir1, <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved <br />010B No. 2040-ts1.'i.. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE / 2i l _I a <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 /> 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 1,er1in under penalty of hrw that this documrnt and all attachments werr <br />prepared rmder mN direction or w <br />rnsion in aeeordarwe %ith a s <br />stem d"i%ned TELEPHONE DATE <br /> <br />- - t <br />= <br />1 ? <br />?? -? <br />? p <br />y <br />b, uuun Hhot qualirnvl per,onnel proprrly Rather and rs,dualr the information <br />/ <br />. <br />- <br />• <br />? <br />- .nhmittad. Basrd on my inquire of thr prnon or prrwm who matuRe Ihr sy slrm• ? <br />-- <br /> or tfi <br />v Ixrsons dinnlh re.ponsibir for Rathering the information. the information JC.,/ -?- - "' - - --. <br />-, <br />? - <br />' : <br />uhmitl d i, to the Ix•+t of rn? Anowlydue and belief. trne. aa•ruraw. -d complete. , <br />'--' • " - t - - <br /> <br />`-' - <br /> <br />t am aware that tM•rr <br />nifiaront <br />emdtir• for wbmiuin <br />f <br />ls <br />tion <br />re <br />i <br />i <br />for <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br />TYPED OR PRINTED p <br />. <br />a <br />. <br />g <br />R <br />a <br />e <br />n <br />ma <br />including thr p-ibilit? of roar and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />tyE I' <br />rwUt <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used This is a 4-part form. R