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PERMITTEE NAME; ADDRESS, <br />l.tt'IuJrFrx'ilir ,v(unr.h.nurionrJpi(/ertnn <br />NAME <br />ADDRESS I.-CH LOADUVT <br />FACILITY <br />LOCATION <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 1 -1 TO <br />Forn <br />OMF' <br />NOTE: Read Instructions before completing 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 +. If Rf_PDili f r C E <br /> REQUIREMENT (ii?f?iTN <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 <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 -1 0% undo: p:nalr.. ; lal, that this document and all attachments were <br />d <br />i <br />d <br />tb <br />d <br />d <br />d <br />• <br />d TELEPHONE DATE <br /> ance wt <br />prepare <br />er in <br />, <br />necnon or supervis <br />on in accor <br />a sistern <br />esigne <br />un <br /> to assure that q'itied personmtl properl}' gather and er'aluate the information \ <br /> submitted Based on my inquiq of the pc•r,on or persons "ho manage the s}, <br />l 11 <br />er <br /> or those per>nm directly resronsible for gathcrmg the information, the information <br /> submitted ts. to the best of my knimledgc and belief. true. accurate, and r-•mplete <br />hu,-- 1"r s <br />tion <br />th <br />t th <br />r <br />ifi <br />t <br />hmittm <br />f <br />ls <br />inf <br />rm <br />I SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am aware <br />ere a <br />e sign <br />can <br />pena <br />u <br />g <br />a <br />e <br />o <br />a <br />. <br />a <br />including the powbthty of fine and imprfu•a:n ni for ku,•?cmg cwlanons O ICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> COOS <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />?021 C This is a 4 -part fonn. <br />PAGE OF