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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDierent) <br />NAME <br />!, + <br />'= <br />7I . <br />ADDRESS IA Yt t 3 <br />I?S r i (3:`;,.. f k;,= •`. <br />y <br />j :"MIX <br /> <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT DM OMB No. 2040-0004 <br /> <br /> <br /> PERMIT NUMBER DISCHARGE NUMBER _. <br /> I t t4 n <br /> <br /> MONITORING PERIOD '.'= <br /> YEAR MO DAY YEAR MO DAY <br />FROM _ t 1 w'd ? C" TO _P ' Q. _- ; s ? )is 3 ' c:,- r_: C : r <br /> <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE it '1•':• « J:i- ..... - ... ..., .... cn•?:• , r;. a <br /> MEASUREMENT <br /> PERMIT <br />_ t 7t! T 4 ?c c* t REQUIREMENT ; t <br />F <br />.?4 l S 1r? <br /> <br />t[4 ?? i :.,J;-l <br /> <br />4_? ( <br /> <br />6'?•' "7 t ! <br />Mai .. SAMPLE .x i .:'x t f i i . i n <br /> MEASUREMENT <br />,,. <br />{'? fr <br />PERMIT <br />Kt t :> F= ;k <br />st.t:;1 st <br />#. <br />F:: a #:fl <br />,=ins <br />t <br /> <br />? <br />E <br /> <br />v'a <br />r I l??'?! '•^` °`a t kt v REQUIREMENT } r <br />01 L. , ti• SAMPLE a c.4.... #,. t . . <br />y J <br /> MEASUREMENT <br /> PERMIT I'3 tiiK <br />G! C. f S <br />t . REQUIREMENT {c <br />µ <br />. <br />L. =?' SAMPLE $ d }3c W :,..., z: t•d? `.:.:. ?s .. s . st <br />THE a ? ZPTM!:,rt1 " MEASUREMENT <br />~"•C"_ " _?^ PERMIT T x_ 3. # <br /> <br />1 <br />C, Ij fn r <br />F 4lr[tiE I ,Svi 'w V, REQUIREMENT 'v'ii <br />1-0 <br /> <br />l_. <br /> <br />t <br />L.. e F , . , = SAMPLE <br />VT <br />MEASUREMENT <br />.., f <br />.? ... - <br />PERMIT <br />-?- • ,Z :i- * '' <br />1 ' ` <br />-:? ? ?. •, <br />t •tt <br />..x. <br />«.. r _ .,. A REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DA TE <br />`4 prepared under my direction or supervision in accordance with a system designed <br />? <br />jet C_Y "-w- ik r M b(. K. Aso ? to assure that qualified personnel properly gather and evaluate the information <br /> <br />q <br />C 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 r <br />C <br /> <br />if 1 <br />-??r ' 9 ` <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br />I <br />h <br />SIGNATURE OF PRIN IPAL EXECUTIVE <br /> <br />® a e? <br /> <br />`?' ?f <br /> am aware t <br />at there are significant penalties for submitting false information, <br /> <br />TYPED OR PRINTED <br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br /> <br />r'nRA11AFAITA AKII1 CVDI AKIATlf%Kl AC A41V \rll11 <br />AT1r%K10 ie_s_._..__ CODE DAY <br />.•?`_.. .. ?::. -•? ._. _. :.. i_'_. ?. [. :. .- a .-..; -9.: ., :- _. ,.. ._. > .,.. i. ? ._ .: .?I Ey i.-.i.. 1;:' rte,>? et-._.. L.,. 4 .ct.....1 ,'sti tv <br />w _ <br />(...5? -FAG Form 3320-1 (Rev. 3/99) Previous editions may be used r t16 ; ?? E R OF