Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME r' <br />ADDRESS =t ° •i ' <br />FACILITY }' 3 } • ' <br />LOCATION <br />Form Approved. li <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />Fi 1) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO: DAY YEAR MQ DAY <br />FROM TO f. a. "` ;•i a ap If t?s=;F E j <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br /># J?..:`'r <br />SAMPLE <br />54-9 <br />J? S <br />S <br />t 'v ; <br />?ZS <br />I/Q ^ . p <br />T?v <br />C <br />' MEASUREMENT y S <br />`e- PERMIT i..,; <br /> REQUIREMENT <br /> <br /> <br />1 ;r? r. <br />SAMPLE f:- J St.'s, a- :i, <br />m: <br />'! <br />:. . • ... <br />.? ., .y'C..r!•:G :a <br />.: <br />..., r, t <br />)/' <br /> <br />?j LSUA <br /> MEASUREMENT <br />?? r • PERMIT _ <br />i g ! I ft REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT; <br />NAMErrITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty`of law that this document and an attachments were TELEPHONE 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 />h . <br /> e system, <br />submitted. Based on my inquiry of the person or persons who manage t <br />or those persons directly responsible for gathering the information, the information <br />c:% 7,-, <br />p} f <br />e <br />O Q <br />v <br />?? <br />r` <br />? <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />LO 6?} <br />t <br />t <br />CO-) L( <br />f3 <br />T <br />` <br />-• I am aware that there are significant penalties for submitting false information, AREA <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations.- OFFICER OR AUTHORIZED AGENT <br />CODE NUMBER YEAR MO DAY <br />COMMENTS AND txF'LANAIIUIV Ur' ANT VIULAIIUVSI? (deference An c-tttztctttttrnw nrtr/ <br />j, 0: <br />F 17 I'll r- "ki -) a. <br />i i. fJ;j; { lT 1St15yeT 4' On-n. PAGE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. -