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PERMITTEE NAME/ADDRESS / omi.& fwduyNowdrLecrmn l(DWw-u) <br />NAME <br />ADDRESS <br />FACILITY J',J Y U 1`I Nz <br />LOCATION ER L t <br />Y 7 ,'P OF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (O R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO. DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />M I Fr OMS No 2040.0004 <br />DOE 3AR 5 F1OND, T0 W I1 SON CR <br />NOTE: Reed Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQU£NCY SAMPLE <br /> <br />L <br />< OF <br /> ?! <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />" .- <br />MAXIMUM <br />UNITS <br />EX <br />ANALYSIS <br />TYPE <br /> SAMPLE <br /> MEASUREMENT <br /> <br />1 PERMIT <br /> <br />REQUIREMENT t •?, <br /> <br />•h i MI_!~! <br />. <br />n ,T} <br />.SIC;. ! <br /> <br />-, -., SAMPLE <br /> MEASUREMENT <br /> , <br /> PERMIT <br /> REQUIREMENT H I l.Y ( <br />DA 1'1Uf! t <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br />• PERMIT ?XWA TA 1 1 . Y ;1X <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT : 'Ti-)A <br />!?V'G <br />CA I L. 'r r';t <br /> REQUIREMENT <br /> - ,s ?} N ,# <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT x hSQjV•?' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMnE PRINCIPAL EXECUTIVE OFFICER ' nrtuy ° K penally o law that thlr document and an attachments wore <br />r <br />d <br />d <br />l -- - _ ??? TELEPHONE DAT <br /> <br />prtpa <br />r <br />un <br />or mr dlrxt <br />on or wpers!>ton In accordance with • system designed E <br /> to assure that ".Mfted ptrsonml Properly gather and ...Juan the Inronnollpn <br />submllted. Dowd on mi Inquiry of iht Person or portion, who manage the tytttrn, ..- <br /> or those pennna directly respordbk im gathtrtrtg the Information, the Information <br />e <br />L T..7 <br />?I L-.. y ) l V r • J ' ,_?r?, <br />- . c ?. submllttd k, to the best of my bnowkdp and belief. trot. accurst. and tompkte. ry <br />?? ? <br />, : c , <br /> I am aware that then: are stgnlllcant Penalties for aabntltdng raise Information, SIGNATURE OF PRINCWAL EXECUTIVE [U <br />- I <br />. 4 <br />TYPED OR PRINTED Inckrding the poadblDly of Ilne and Imprisonment for knowing Aciation? OFFICER OR AUTHORIZED AGENT AE <br />A <br />CODE NUMBER YEAR MO DAY <br />CoMMEN 1 S ANO EXPLA NA+1 wrr yr ANY .tests 1IVPI4 tnererence yr erre-Cnments nerel 4HR P-REi; I P EVENT 15 CLAIMED. 1F CLAIM APPROVE T' <br />OFF. A. c: - -r?J V _ <br />zy IJT?? i ION <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used PAGE OF <br />This is a4 -pa`rrf6r?n.