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PERMITTEE NAMEIADDRESS (6sclude Facility NamelLocation if Different) ?
<br />NAME
<br />ADDRESS
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<br />FACILITY
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<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />OMB No. 2040-0004 ,
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER 5 „• ??I. tl. ?f
<br />MONITORING PERIOD K :i\i D, .. ' I "Ti
<br />YEAR MO DAY YEAR MO DAY
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<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE
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<br />AVERAGE
<br />MAXIMUM
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<br />MINIMUM
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and an attachments were TELEPHONE
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<br />prepared under my direction or supervision in accordance with a system designed DA TE
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<br />(C?/ (/? / i ?f \? 'J to assure that qualified personnel properly gather and evaluate the information
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<br />[lased on my in
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<br />persons w
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<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 />SIGNATURE OF PRINCIPAL r, . +*'
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<br /> am aware
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<br />icant penalties for submitting false information, EXECUTIVE N
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<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY
<br />COMMENTS ANn FXPLANOTIAN nP eNV VInI ATlntue /J2_An -:,, .,n .a a .. ?___, CODE
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<br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used.
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