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PERMITTEE NAMEJADDRESS (tn" faethrym'-*"oearron (/D(Qirwrt) <br />NAME <br />ADDRESS <br />FACILITY Gwyu 'I : NE <br />LOCATION <br />_.L-Y L,rt!?1TJE_? t,, F; <br />NATIONAL POLLUTANT OISCHMOE ELIMINATION SYSTEM NPDESJ <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 />M I OMB No 2040-0004 <br />NOTE: Read Itmttuctiom befw• comolatlna thle form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />? <br />'{ <br /> MEASUREMENT " ) <br /> <br /> PERMIT <br /> REQUIREMENT f MUM <br /> SAMPLE <br />MEASUREMENT <br /> - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT ; <br />r <br /> <br /> PERMIT <br /> <br />REQUIREMENT _ (;L-A A,:r_. IiFe : t._ t • X <br /> SAMPLE <br />MEASUREMENT <br />C 'l C? <br />n f <br />??•` <br />( <br />1 - <br /> f <br />• ; , <br /> <br /> PERMIT <br /> REQUIREMENT D.^- ?; Y •' r,r,,-,. <br /> SAMPLE <br />MEASUREMENT <br />v f ,,- <br />i j <br /> <br /> PERMIT <br />REQUIREMENT <br />T J;? i MAX <br /> SAMPLE <br />MEASUREMENT j --. <br /> <br /> PERMIT <br />caV f :; = REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certuy under Pena y o law that thls donrmrnl and all Hfachm <br />prepared under my d1mr1lon or wpersilon In secordann with • ents were <br />system dalgrrF <br />TELEPHONE <br />DATE <br />•. - T_ j /` r 7 / I / <br />_-- G C l to aMem that quaMM1ed personnel properly gather and e.ahratr the tnrorma(lon <br />submitted <br />eaed en my In <br />uir <br />of tM <br />rrmn o <br />h -?- <br /> q <br />. <br />y <br />p <br />r persoro w <br />o mans=e the system, <br />r th <br />l <br />t <br />i <br />1 <br />- <br />• <br />? <br />A o <br />y resporss <br />ose penom direct <br />ble for pthet <br />ng the tnformstlon, the Inro, m Hon t?•' y ?? h <br />c ? <br /> <br /> <br />; <br />? <br />J C it <br />L. <br />l y <br />' <br /> <br />submlited Is, to the bell of my tnewkdge end belle(, true. accunle. and rompkte. r <br />1?% r <br />? <br /> <br />? / <br />/ <br /> <br />J <br /> I sm swan that then are stpslflew p-Ifla roe wbmlrtlnj false Informatlon, SIGNATURE OF PRINCIPAL EXECUTI`W <br />TYPED OR PRINTED <br />NY VI Indudirrt the poadbluy of Ilse and Imprhonrnent for tnowing.Idatloru <br />T OFFICER OR AUTHORIZED AGENT CAREA ODE NUM9ER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF A OLA" IONS frfvfvrvnc• off attachments horej <br />R PRECIP EVEN"" IS CLAIMED. IF CLAIM APPF?OVED <br />_ :IBC IONS <br />EPA Form 3320-1 (Rev 3:99) Previous editions may be used OF <br />TI!(IS (5-7, 4-part forth. PAGE