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PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different)
<br />NAME
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER [DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM {. Q (31 ') 1 TO ... i ,, 'i:7. ° --:?
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions before Eompleting this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION No. FREQUENCY
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were TELEPHONE DATE
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<br />' prepared under my direction or supervision in accordance with a system designed
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<br />' submitted. Rased on my inquiry of the person or persons who manage the system,
<br />or those persons directly responsible for gathering the information, the information
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<br />. e and belief
<br />true
<br />accurate
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<br />, RE OF PRINCIPAL EXECUTIVE
<br />SIGNAT 644 f
<br /> 1 am aware that there are significant penalties for submitting false information, NT
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<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED A
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<br />C NUMBER YEAR M DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />Ottppp, PAGE ?OF
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used., ` y, ^riS SgI a L.. .
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