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PERMITTEE NAMEIADDRESS 11nelude Farifirt Name/Grradoo if Differeali <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />.'i'_r :t. i• 1, c n!C T nIFT=R <br />L <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO <br /> <br />. <br />FREQUENCY <br /> <br />OF <br /> <br />SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ?? ;} I ? SIrV <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r i :7 <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br />J <br />?' <br />f <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE t }. A? <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT 1 <br /> <br /> SAMPLE r a, <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT - <br /> <br />SAMPLE e.: <br /> <br />! <br /> <br />1 \;a L <br /> MEASUREMENT 1 <br /> <br />PERMIT 7-7 <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER t a•nif7 under penalq of law that this d,.untrnt and all anarhmrnts wen- i - TELEPHONE DATE <br /> prrpared under m? dirtctinn or cube 00on in accordance with u system designed <br />1 ^? ( In a-um that qualified pe-onnel pr»lRrl% gather and r%.II1W If the mromiation <br />e the s <br />stem <br />-n or <br />erson. »bn mana <br />h <br />i <br />i <br />f the <br />i <br />d <br />B <br />d <br /> <br />,- . <br />p <br />g <br />y <br />.u <br />on my <br />nyu <br />r o <br />pe <br />m <br />tte <br />. <br />use <br />or thaw persons di-ctlt rrsponsihle f ,r gathering the information. the inrormation <br /> <br />i <br />? <br />Y suhmitled ts, to the best of m. An Irvlge and belief. tme, accurutr, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE v <br />, C• r , -_. <br />_. _ I - ! ) ! ? i <br /> am aware that them am sigmncanl penalties for submitting fide information. AREA <br /> risonment for knowing riolutions. <br />ssihditt f fi <br />e a <br />d im <br />iudi <br />th <br />i OFFICER OR AUTHORIZED AGENT NUMBER <br />E YEAR MO DAY <br />TYPED OR PRINTED e la <br />p <br />nr <br />ne <br />n <br />n COD COMMENTS AND EXPLANAIIUN Ul- ANT VIOL 4IIUIVa Irreferent:e drf dildQftrftefrl3 rrcfal <br /> <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used- This i . a 4-part forni.