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PERMITTEE NAME/ADDRESS (Include Facility Name/LocationfDiiferentj <br />NAME <br />ADDRESSt-`< <br />FACILITY <br />LOCATION`a <br />f <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) r? tom: OMB No. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD ` <br />YEAR MO., DAY R MQDAY <br />FROM YEA <br />TO 1:1 1 <br />AInTF• Pond hafnra <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br />YPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS T <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ,. <br /> <br />. REQUIREMENT <br />, SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT `. <br />._ <br />._ 3-l <br />_ <br />... <br /> SAMPLE <br />-• - MEASUREMENT <br /> PERMIT „ =r <br /> REQUIREMENT : t <br />l SAMPLE . . <br /> MEASUREMENT <br />' PERMIT <br /> REQUIREMENT <br /> SAMPLE " .: .. .. <br /> MEASUREMENT ° <br /> PERMIT .. t <br /> REQUIREMENT e e _ <br /> ... <br />. <br /> SAMPLE ; <br />>: r .. <br /> MEASUREMENT <br /> PERMIT , 1 s,- , „ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :c -, .•.. c ..., 1 .i,: , ,, <br /> REQUIREMENT _ • . i , ;r <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br />- <br />t f? - - ; u 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 <br />Ba <br />m <br />d <br />i <br />i <br />f th <br />h <br /> . <br />y <br />se <br />on <br />nqu <br />ry o <br />e person or persons w <br />o 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. <br />I <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />t. ? <br />I t L <br />f / l <br /> am aware that there are significant penalties for submitting false information, . <br />TYPED-OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />CnMI1ACAITC AA1n CYDI AAIATlf%Kl AC AsIV 111n1 ATIn LIC io..?___...._ _11 -- <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. '.ice' This ..... 4.p" 1 orm. PAGE OF