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PERMITTEENAMErADDRESS,maulefwmin %am,LocarioniifDi errnt; <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION is FN co <br />-IN ti?=:'•ti•iANr OPERATOR <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 />Form Appre:c-d. <br />OMB No. 2040-0004 <br />NOTE: Reid li structions 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 <br /> REQUIREMENT ?.• • : r I'l l i N1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT if sr= I< f # 1; -.0 t; I C E -• 13 <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT iir+ ?? s ??1=f'0f%T i11t?L, ..Ric,; <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - r. * x M rt r <br /> REQUIREMENT r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT f7.J <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 'ORT ,'.•v trti = - i1Fii> <br /> REQUIREMENT qv(; i <br /> SAMPLE ?t •t; it <br /> MEASUREMENT <br /> <br />PERMIT .R <br />s # <br />z <br />R EP OR T <br />- F Ccr'd <br />1 <br />- <br /> REQUIREMENT ;,DA ; ty:? <br />NAMEJITLE PRINCIPAL EXECUTIVE OFFICER I ccrufy under penalty of Inw that this document and all atruhments acre <br />c TELEPHONE DATE <br /> prcparcd under my dire <br />tion or supemtsion in accordance with a System designed 1 \ <br /> to astiure that qualiticd persnmui properly gather and csaluate the infonnatron It <br /> submitted- Based on my inquiry of the person or perxms who manage the system, <br /> or those persons directly responsible for gathering the information. the information --? - <br /> submitted is, to the hest lf mp knowledge and belief, true, accurate, :md complete. <br />s f <br />th <br />t th <br />lt <br />I <br />mfi <br />t <br />b <br />tti <br />t <br />k <br />t <br />fo SIGNATURE OF PRINCIPAL EXECUTIVE Ill )-.. L./ <br /> <br />TYPED OR PRINTED ,am aware <br />a <br />ere arc sig <br />can <br />pena <br />ie <br />or su <br />mr <br />ne <br />a <br />e in <br />rma <br />ion. <br />including the possibility of fine and imprisonment tin know Ittg , ItAitiuns OFFICER OR /(UTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> CODE <br /> <br />'C IP EVENT 9UT_. .)ECT TO BURD1 <br />C) ?HE DIt," I .4 -)ra WITHIN 48 t <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ()20This l9 a.4-part form. PAGE i