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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if'Dierent)
<br />NAME
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<br />ADDRESS
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<br />FACILITY r ti•. tst fy +.r.J'..r {
<br />LOCATION,
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<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 r_
<br />Form Approved. 41
<br />OMB No. 2040-0004
<br />NOTE: Read Instructions before comnietino this form. f
<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
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<br /> MEASUREMENT
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<br /> REQUIREMENT M, i-f t T P .i's'' t f?•i t?{ t_
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<br />l) ;I,'i?;i MEASUREMENT
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<br />?' L.? I? i ri 4 w?v ?P LIB REQUIREMENT
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<br /> MEASUREMENT
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<br />Tw a AI_ "t rf>L ?+i ;5l" k ..,7 MEASUREMENT
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<br />C"Q REQUIREMENT
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br /> REQUIREMENT
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<br />1-0 MEASUREMENT
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<br />D X. S 01C L V`-,1; MEASUREMENT
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<br /> REQUIREMENT Jt M :. Y "- t ^1 ?:
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br /> to assure that qualified personnel properly gather and evaluate the information
<br />submitted. Based on my inquiry of the person or persons who manage the system,
<br /> or those persons directly responsible for gathering the information, the information
<br /> submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />SIGN TORE OF PRINCIPAL EXECUTIVE C y
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<br />TYPED OR PRINTED on,
<br />am aware
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<br />including the possibility of fine and imprisonment for knowing violations. O FILER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />livmmtrv IJ ANU tArLANAI IVN Vr ANT YIVLAI IVNA Ilrfererence an aaacnmenis nere)
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<br />EPA S ?t .a ?'iI`J?3•?t'"
<br />Form 3320-1 Rev. 3/99 Previous editions may be used. yr., ?iisa_4 itllx, OriT1. rArat
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