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i <br />FERMITTEE NAWJADDRESSR•A`FecOrylv..?L*eoti-(/D(Y-t) <br />NAME <br />ADDRESS <br />I <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATON SYSTE4 <br />DISCHARGE MONITORING REPORT (DMP/ 0004 <br />PERMIT NUMBER aNUMBER <br />MONITORING PERIOD <br />t 7, _,. <br />YEAR MO DAY YEAR MO DAY J <br />FROM TO <br />NOTE' Read ItrMU-Herr h.f-. r•nnnwl.tMn ehl. f-- <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPA4 EXECUTIVE OFFICER I Benny under pen. ry dI.. that thi <br />prepared coder mr direction or wpe s dorslment and al .llwhm <br />r+islon In trecord.nn srllh . enb <br />s)tlrm dol <br />ned <br />TELEPHONE <br />DATE <br /> g <br />In assure that qu.HHrd perso..el Property gather and e+aturde it, <br /> <br />! submllled. Bawd on m( Inquiry of the <br />non prr or..ho manage the system, <br />nr tbox r <br />r <br />directly <br />lbk f <br />h <br />i <br /> <br /> <br />': <br />. <br />. <br />' sons <br />M <br />n <br />gat <br />er <br />ng <br />or the Information, the Information <br />u <br />bmltl <br />d b <br />k <br />h <br />( <br />/7 <br />- fi7? <br />-7 <br />• <br />_ <br />e .. <br />• G . <br />i s <br />e <br />. to t <br />e ?t 0 <br />rgw4dge and belief. true. rKe•urate..rld comkte. <br />m7 <br />I .m that then .n slgnlfk.m penalties for rrbmllting f.be inform.tl <br />n <br />6IGNATURE OF PRINCNAL EXECU Vf <br />- - <br /> <br />TYPED OR PRINTED <br />..w. . . ..r. T1 A11 AC a.IV 'I'-' . <br />o <br />Inchrdl.g the possibility or line ¦nd Imprisonment for knowing rlel„tlorm <br />OFFICER OR AUTHORIZED AGENT -WE <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />*C: I rl' (_ rt: - - A PL !_ ,jar - r I ?7F h,t - c t'L_AIf MR-D. r •,F1? .:; ?' )C1t'r` <br /> <br />ESA form 3320 1 (Rev 3f99) Pfevlou4 ed dons may be used <br />ThIS Is-a?3-part form. PAGE OF <br /> 0016S/05t- . I .- -i l