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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDierent) <br />NAME t , _ i T , rf <br />ADDRESS { K_t':` <br />FACILITY <br />LOCATION(-.: <br />', <br />to r - "i: <br />A <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) i?l `r. K t;' <br />PERMIT NUMBER DISCHARGE NUMBER ; ?= 7?':`w? , ' <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM <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 />' _. _ ., . -.. :. SAMPLE :., .- .. r <br />i7;;r?=``:: MEASUREMENT <br /> r3• <br /># .. z x # ..E ! , 4. <br /> PERMIT . . <br />! 1. s i._r REQUIREMENT _ i A`!',` DA £ L, v N X 'C r` .. flOtEt T <br /> SAMPLE <br />s ; `ms's r'- i ' « MEASUREMENT <br /> x itq Mx st x- r# a f # A s <br />a , f F e ,t <br />€° LI <br /> <br />S. <br />L <br /> PERMIT <br />R <br />t.:FFL.' ti)-J-f E REQUIREMENT }r 1 f ?!`w €. ! (_ r 'i * t.. <br />,l ti (r ftii #'F€ <br />..s _ SAMPLE i i..r. £. i . •Sd .. .., } x , ::'... r <br /> MEASUREMENT <br />' r <br />PERMIT <br />xffrt s€ <br />'••-. z <br />: :1 <br />r <br />r <br />F, i <br />, <br /> <br />?. <br /> <br />1:- x € <br />77, rx Lrr <br />REQUIREMENT <br />S { <br />? <br />d :. _ .. SAMPLE r a :a •.., is ... : --r ,L <br />=21?S_.'? MEASUREMENT <br />r ti *+.:, 44, :'t t 411 t ?° # L I-JmC,:._ -/1 -A J. €,,.,.1 <br /> PERMIT MON i IS <br /> REQUIREMENT <br /> SAMPLE .! ? a ?i ?......• r : _' <br /> MEASUREMENT <br /> PERMIT ats. _ g f .. ?r F•$ c #:, a:.-? rsa ;r::' -.-. x t l J Fa r _3 <br />V S r r s>!., Iii':. <br />r. REQUIREMENT d 'r zi ti - t: (1034 <br />,.i `.` .. • .'f r _ - SAMPLE <br />.,.?+. <br />;'.# <br />r r-x <br />s d <br />t„Pf="'ri=.•t),_ay MEASUREMENT <br /> k3 sr f <br />ate. <br />! '? K 3e 4 t.h..a. ; i € _ <br /> PERMIT <br />:.F REQUIREMENT <br />t'' <br />?. f+ <br />MOIN , H' <br />'? .. •_; :.. _. SAMPLE <br />ci •'d`;3_ MEASUREMENT <br /> LAI <br />U111 <br />'! <br /> <br /> <br />`. . _ ,. - PERMIT <br /> <br />REQUIREMENT <br /> <br />" <br />_ A`?t_' <br />l <br />NT1-1 <br />fii 3 <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br />A prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the a <br /> <br /> <br />L CC ` 1 ?- v <br />s <br />ge the system, <br />submitted. Based on my inquiry of the person or persons who manage the system, <br /> the information <br />onsible for gathering the information <br />res <br />or those <br />ersons directl r. <br />` /1 <br /> , <br />p <br />p <br />y <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ?I (r <br />I E r??? ld V <br /> I am aware that there are significant penalties for submitting false information, <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PAINTED ons. <br />including the possibility of fine and imprisonment for knowing violat CODE <br />COMMENTS AND LAYLANAI IUN Ur ANY VIUL141IUNa Ir?ererence a?? auacnmc??w nC?e't <br />PAGE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 000.-.t !0 : I A'0t 44pattfo m•