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PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDii erent!
<br />NAME
<br />ADDRESS
<br />FACILITY %tz
<br />LOCATIONr.? -i t
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) t: OMB No. 2040-0004
<br />PERMIT NUMBER DISCHARGE NUMBER" :T• " It'`? 1' - ?i`'
<br />MONITORING PERIOD D3 i 1 .:,
<br />YEAR MO DAY YEAR MO DAY
<br />FROM TO
<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
<br /> MEASUREMENT
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<br /> PERMIT
<br />L.}jb REQUIREMENT r
<br />NAMEJITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed
<br />'S TIC Pµ eA( DC,( -r'®,?-4 to assure that qualified personnel properly gather and evaluate the information
<br />11 submitted. Based on my inquiry of the person or persons who manage the system, V
<br /> the information
<br />or those persons directly responsible for gathering the information s
<br />?
<br /> ,
<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE
<br />% ry y ?1 ( f
<br />
<br />TYPED OR PRINTED I am aware that there are significant penalties for submitting false information
<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 EXPLANAI IUN UI- ANY VIULAI IUNS (Kererence an alracnments nerej
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. t 3 j;?r?t ? rrf?1 ?i yt `43? tform PAGE 71 OF G?'
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