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PERMITTEE NAME/ADDRESS (Include Facility Name/Location rfDiJjerent) <br />NAME <br />ADDRESS'` :47 ii'i' !J ..'...I. <br />FACILITY t_ .. <br />LOCATION <br />r?. 1 ,: , - tr-I <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 Approved. <br />OMB No. 2040-0004 <br />N. 2.? <br />j• 1 t.l.lA! ^vtY«?:??tr <br />.i }:'.. ..?5 a •`'F»}'-• .c??±t;: : `?? .'i"'sa;Yw <br />NATF- Raarl Inctruetinna hafnra emmnlatinn thic fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE x ° t... r c .... ti _. <br /> MEASUREMENT <br /> PERMIT ._. • - .. <br /> REQUIREMENT y <br />- SAMPLE <br />H MEASUREMENT <br /> PERMIT <br />7. <br />77- 17 <br />{._, sw•r r . a?.. t.:^ri_I!'- REQUIREMENT s: <br />4 <br /> SAMPLE r - : ;> .. _ • ,; <br /> MEASUREMENT <br /> PERMIT <br />„i "L_`."_;?:. REQUIREMENT .. _ .3 -•# r', .. ._ 'r.....-, i.. I''g-.:r''._ ' I'.+? , :i <br /> SAMPLE <br />I w= _. F i? ." Y A:, 1-': <br />MEASUREMENT <br /> PERMIT 77-1 77: <br /> REQUIREMENT z'b 's •. ? .'% `:' a;`!; <br /> SAMPLE <br />ti„'?i•?. ¢=`.:'..`It';Li=;."?.,% MEASUREMENT <br /> PERMIT <br />F 'u'• . . . i.s•)'" REQUIREMENT <br /> SAMPLE ...' <br />$i:``''<•a.• MEASUREMENT <br /> PERMIT t <br />: .. REQUIREMENT ?-....: •:.. :: -. ? :; v;; : _ -;° ii''' <br /> SAMPLE ti <br />F i, ??y=3 ,-•. „i,''._ i`:, .`.?t.. w? MEASUREMENT <br /> <br /> PERMIT 5r _. <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were T ELEPHON 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 />; <br /> submitted. Based on my inquiry of the person or persons who manage the system, ' <br />t nr those persons directly responsible for gathering the information, the information .,.? •, ?: <br />y t ? f, submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />I <br />h <br />h <br />i <br />if SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> <br /> <br />TYPED OR PRINTED <br />am aware t <br />ere are s <br />at t <br />gn <br />icant penalties for submitting false information, <br />including the possibility of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED <br />AGENT" <br />` AREA <br /> <br />CODE <br /> <br />NUMBER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />?/VI?IIYI VIA I V AI\Y ?/?I rr„?r'I,IV1? v1 I.11?, •IVLr111 V1?V IIIGICI CII{iC all aasa411111vitto IICICl <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br />,"t00*' -'0'.Tlis?is'h-41p9ft)-form. <br />PAGE •; a OF