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PERMITTEE NAMEiADDRESS an. L..1. r.r..hn scan <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />_ U Form Approved. <br />I ?- OMB No. 2040-0004 <br />NOTE: Read Instructions before comoletina 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 <br /> MEASUREMENT <br /> PERMIT s s? ;ri i =2L Y' <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 i certify under pennln of law that this documcnt and all attachments were <br />d <br />nd <br />r m <br />d <br />r <br />cti <br />n or su <br />ervi <br />ion <br />rd <br />ith <br />te <br />d <br />d TELEPHONE DATE <br />prepare <br />u <br />e <br />y <br />i <br />e <br />o <br />p <br />in uco <br />ance w <br />a sys <br />esigne <br />s <br />m - <br />nr assure that qualified personnel properly gather and rsaluate the information <br />? <br />- <br />' <br />?% - - <br />- <br />.:: -f <br />; • ?- <br />. <br />? submitted- Eased on my inquiry of the person or persons who manage the system - - - <br />) <br />of those persons dtrntly responsible for gathering die information. the information <br />to the Nst of my knmcledee and belief <br />rne. accurate <br />and complete <br />C submitted is <br />, <br />, <br />, <br />I inn aware that there are stgmticara penalties for ;ubmtting false adorinaunn SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED including the powihdm of tine as l nn^n, •nn!,m for knowme ,u,,Wiom OFFICER OR AUTHORIZED AGENT I AREA <br />NUMBER <br />YEAR <br />MO <br />D11Y <br /> CODE <br />GUMMr-NI, ANU CAI'LANAI IUN Ur ANY VIUL.AIIUN, (Hererence are artacnments here) <br />-!R REI <br />CAI API <br />EPA Form 3320-1 (Rev. 3.59) Previous editions may be used. D009t- Thi9 i3 a 4- rart form.