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PERMITTEE NAME)ADDRESS(Mrs.&&FrWeyN..?Larrsan((D(fi wr) <br />NAME <br />WIf <br />ADDRESS 3W y <br />i <br />FACILITY I^ E H <br />LOCATION r'le)lf <br />'^ ER <br />t t ? <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTEM (NPDE,SJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHAAGE NUMBER <br />Form Approv?d <br />OMB No 2040.0004 <br />F - r -INAL fr <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY ^ t `" 1 % ?l r. : ^r <br />c <br />FROM TO <br />NOTE: Reed h»tructlond before' completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <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 i <br />REQUIREMENT <br /> <br /> <br />document and aM ¦11schmente veers <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER " " penalty ° aw that thN <br />' "^" y <br />TELEPHONE <br /> <br /> <br />ATE <br />_ prepared under my dlrsctlon or mie-Iston to •tcord•nrv with a system designed <br />_ i •' 1. to ,sort that qualified personnel Properly gather and evaluate the Infnrm•tlon '?- <br />h <br />? <br />~l <br />- mbmltled. Based on my Inquiry of t <br />e person or persons who manage the syslem, G?< 7y <br />_ <br />f y <br />or those <br />er <br />o <br />dir <br />tl <br />res <br />f <br />athe <br />f <br />ibl <br />i <br />th <br />I <br />y <br />p <br />na <br />ec <br />or g <br />r <br />ng <br />s <br />pons <br />e <br />e <br />n <br />ormation, the Information <br />Y I - •1? <br />)1 ?? <br />mbml u.d h <br />to the best of my kw.kdte and be1Mf <br />Iron <br />; <br />el. ?,L- 1 J <br />?nle <br />and ccm <br />ku <br /> <br />. <br />?• <br />/O <br />_ _ <br />.. ( . .__ <br />. <br />r <br />. <br />. <br />. <br />p <br />. <br />I am aware that there art significant penalt!" for e"brtitnng false lnf°nn.tion, SIGNATURE OF PRtNCWAL EXECUTIVE . <br />..- <br />/ <br /> In <br />ludin <br />th <br />ibilit <br />f fin <br />nd Im <br />t r <br />ri <br />TYPED OR PRINTED c <br />g <br />e poss <br />y o <br />e a <br />p <br />sonmen <br />" knowing vldatlo OFFICER OR AUTHORIZED AGENT COOS NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OI- AN <br />This <br />EPAFtifrn'3320-1 IRev 3/99) Previous editions may be used is:a4-part form. PAGE OF