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<br />PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different) <br />NAME J tejTi'9 ? i'Oz. <br />ADDRESS <br /> I 'J" -,z..: '- ST E 2r' <br />1 <br /> L t <br />FACILITY ):`y' : . ' i i''•= <br />LOCATION <br /> <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) H NUR <br />PERMIT NUMBER DISCHARGE NUMBER- l-'It <br />1E,r'i TCl VfA... ji Na '11 .c? f j': <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MOS. DAY !" l(_t { w; } Y ?y "' 7 , <br />FROM M _ TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO <br />EX FREQUENCY SAMPLE <br />TYPE <br /> i - ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE. MAXIMUM UNITS. <br /> SAMPLE r .?F _f ;. l,. r'.• .- . .":? r ".r F. i` f <br />-41 SjA <br />V 'i t3 UP41 MEASUREMENT 6 <br />u n?S PERMIT <br />r FI i .i tt--s1 ;' „' REQUIREMENT' <br /> SAMPLE t <br /> MEASUREMENT <br /> PERMIT ) <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE 1 <br /> MEASUREMENT <br /> PERMIT k ^ <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT r <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITL PRINCIPAL EXECUTIV OFFICER I certify under penalty of law that this document and an attachments were <br />i <br />i <br />d <br />d <br />di <br />ti <br />i <br />i <br />d <br />ith <br />t <br />d <br />d <br />e TELEPHON E. DATE <br /> on or superv <br />ance w <br />gne <br />prepare <br />un <br />er my <br />c <br />s <br />on <br />n accor <br />a sys <br />em <br />es <br />r <br />PO41) l&L to assure that qualified lpersonnel properly gather and evaluate the information <br /> submitted. Based on my inquiry of the person or persons who manage the system, <br /> <br />9 or those persons directly responsible for gathering the information, the information <br />J submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br />i <br />ifi <br />lti <br />f <br />itti <br />l <br />i <br />f <br />I <br />h <br />t <br />h <br />t <br />b <br />f <br />ti <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />t/ , <br /> <br />TYPED OR PRINTED am aware t <br />gn <br />can <br />pena <br />es <br />or su <br />m <br />ng <br />a <br />se <br />n <br />orma <br />on, <br />a <br />t <br />ere are s <br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIULAI IUNS (mererence all arracnmenrs nere) <br />if <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br /> <br />0 22 41(ITHN i`Is a 4'-p ftf firm PAGE