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PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different)
<br />NAME L.i', .'+::. `. . , .. ",,?= i-. ?L!t't , .r • ,°
<br />ADDRESS tw;4iJ 3 I ' I?!?{
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<br />FACILITY
<br />LOCATION C U r- i.':.'.
<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT (DMR) r
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<br />MONITORING PERIOD
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<br />NOTE: Read Instructions before completing this form.
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<br />METER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY
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<br />t r t F r REQUIREMENT
<br />TLE PRINCIPAL EXECUTIVE OFFICER I certif y under penalty of law that this document and all attachments were TELEPHONE DATE
<br />NAMEM prepar ed under my direction or supervision in accordance with a system designed
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<br />submit re that qualified personnel properly gather and evaluate the information
<br />ted, Based on my inquiry of the person or persons who manage the system, '
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<br /> submit ted is, to the best of my knowledge and belief, true, accurate, and complete. SI ATUR OF PRINCIPAL EXECUTIVE 1 04
<br />?ifs"•? 1 am a ware that there are significant penalties for submitting false information, IZED AGENT
<br />THO AREA YEAR MO =D
<br />
<br />PED OR PRINTED
<br />includi
<br />ng the possibility of fine and imprisonment for knowing violations.
<br />FFICER OR AU
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<br />CODE
<br />NUMBER
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<br />COMMENTS AND EXPLANAIIUIV Ur ANT VIULIiIIUIVJ I17CIVIC I1 W 011 aua[ .LI?Lw ..?. i
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<br />,,.''c..ot'?`?'?i'?;i?. a 4part?orm.
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.
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