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PERMITTEE NAME/ADDRESS (Include Facility Natne/Loeabon if Different) <br />NAME <br />ADDRESS ''?^._,,: •_.. r .`d .??.:'ta .). <br />FACILITY t t „ <br />LOCATION r. : <br />Form Approved. a <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 - <br />DISCHARGE MONITORING REPORT (DMR) <br />t'•..f a.. } <br />PERMIT NUMBER DISCHARGE NUMBER _ <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO _:,s^ <br />NOTE: Read Instructions before'co iiPIeting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />_' _ .. SAMPLE <br /> MEASUREMENT <br /> PERMIT s :,e_ <br />.. x z ak i l r <br /> REQUIREMENT r <br /> <br />I Ott .j. _?,i .. - .. SAMPLE a f: , .... { . x: .. <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT, f - 1 f <br />s I SAMPLE ..... * ., <br /> MEASUREMENT <br />_ PERMIT <br /> <br />i _f.=`ai € t_•':, z- REQUIREMENT ?• <br />?.. t` SAMPLE i <br />ra MEASUREMENT <br />fa`t PERMIT Y 4. <br />rr :it t __I:?2? r REQUIREMENT <br />? B <br />In <br />i <br />s ,. SAMPLE `" :... .. 't :. . <br />_i"i a., . , --+ . ,.t -%''• A.- MEASUREMENT <br /> PERMIT <br />F?r a =r„T ; r ?r REQUIREMENT 1fi i? `°? z,. ?.• .xr <br /> SAMPLE &± ...:r .. t .. ...., .. s . is <br /> MEASUREMENT <br />. <br />PERMIT <br />y : + r.= 4r. v t t REQUIREMENT <br />P <br /> <br />. • . SAMPLE r <br />? x f ts)-, <br />.:? .; . MEASUREMENT <br /> PERMIT <br />.,I <br />. r <br />t REQUIREMENT <br /> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER [ certify under penalty of law that this document and all attachments were <br /> <br />m desi <br />ned <br />ti <br />i <br />i <br />i <br />d <br />ith <br />t <br />d <br />d <br />di <br />TELEPHONE <br />DATE <br /> g <br />rec <br />on or superv <br />s <br />on <br />n accor <br />ance w <br />a sys <br />e <br />prepare <br />un <br />er my <br />to assure that qualified personnel properly gather and evaluate the information <br /> <br />submitted. Rased on my inquiry of the person or persons who manage the system, ,, <br /> <br />? <br />y or those persons directly responsible for gathering the information, the information -f? <br /> and complete. <br />to the best of my knowledge and belief <br />true <br />accurate <br />submitted is ` <br />' r , <br />, <br />, <br />, <br />itti <br />ls <br />rm <br />ti <br />n <br />ifi <br />t <br />lti <br />f <br />b <br />f <br />i <br />f <br />I <br />th <br />th <br />i SIGNATURE OF PRINCIPAL EXECUTrf/E 4 ` <br />TYPE OR PRINTED , <br />ere are s <br />can <br />pena <br />es <br />or su <br />m <br />ng <br />a <br />e <br />n <br />o <br />a <br />o <br />am aware <br />at <br />gn <br />ossibility of fine and imprisonment for knowing violations <br />includin <br />the OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR Mil DAY <br /> . <br />g <br />p CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATION5 (Heterence all attacnments here) <br />,a r"r, r r'+ .,. .,? _., ..•r' <br />t' <).?xs f ii?. J .. _. _., ...mot. <•? ,_ ._ t.,. ?. A. ._. .. .?... .. irk 7 s•«- X;. ,. ?. .r^L <br />. k ?:». __.. .. `'9lk.J \`. ? :.:+-' ... i <br />t.. .... ., .._ . _. _, <br />., <br /> <br />Form 3320-1 (Rev. 3/99) Previous editions may be used. ?0?.•f, fTYyS1S $-p(tjfOlril. OF <br />PAGE