|
PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME _ r - ,
<br />ADDRESS i3lj, .!, k, ;" _1. :' t l '`?
<br />FACILITY L S r
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARG'?ttE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM r ;,?i. -'j i TO ". ) i
<br />MI ?ir'?Z
<br />F > ;1l
<br />Form Approved.
<br />OMB No. 2040-0004
<br />i4 i._ y F
<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 sn._(.?...:3 a :?3 r,L.t' Z?:::k
<br />
<br /> MEASUREMENT
<br />i; `"F?.; t'e i :. i jy PERMIT #33 1 sf 'k 7 . t- ; ':f •#'P t°..i. ? sr? d't ti #i ? '.; IN ? t.: L f »?R AB
<br />"F3 1 d .` T r. o t } j REQU(REMENT . ?ti t?F }" I 1'll.3i 1, - '0 t)`4 ii..af `E t
<br />??`t e_.2 fY.3r T..) a''?;.... SAMPLE ?f. .. ..#3E 3i• ...,.. .; .?.,. -$C-?V*`1;-?f?:c t Z*?a'.
<br />IROy MEASUREMENT
<br />;`anti 44 Z O PERMIT , #? i f# tfi zj l :z •,:#°i t§ a #i( 3s'7 `.F 45 "{?i wi;`'.; ?;RAiir
<br />l ";. (-,R t 6 REQUIREMENT n.:# # "?' "&A ?4t•r'Ecr' 1'"',Y D A nj( tl..a( r .i
<br />ra _. _. t; r 4 ? ,,'?tLL k. SAMPLE t# =? #1 # l s y, w
<br /> MEASUREMENT
<br />SAMr ti :t } PERMIT ;?"' i:?i4* F€,r•.'r3i t $7d•:d ft i 4 RI POt 1 ?. 'L (a r dLr,I; i
<br />t .r` ?°t? ?% i ('1.
<br />• REQUIREMENT q .,.!i r _?7?'A A'y''" f _ raa
<br />-{ d. .. , t , .
<br />r , t :.? t,, ;s. ;F. . SAMPLE r : t •; y..>x I. d :: ti 71 2t I ... :.._ _d x ;i Ls s
<br /> MEASUREMENT
<br />"
<br />
<br />+ PERMIT d. ?k 3f 3f ,, •#3f # :z # i• :r #f 4 F rr f z ., x _l,'
<br />} E']
<br />>
<br />?.
<br />t;Art
<br />, ?. t_.. aP c t:: '`:>f±al ' }#
<br />r- k REQUIREMENT
<br />?c ,} > y. .4.
<br />7 3",x y ;mot Z _# M14;
<br />» ... >ro _ SAMPLE ti ;3 x : _, t :i ?
<br />T",° RU '»F A T MEt-4T FL jKrNl MEASUREMENT
<br />;
<br />` PERMIT REPORT RE?POIR?a ?g st ut•?{ t r,r• >: =P q,¢. ?# i t-t # w1..t 4l :wll R
<br />j
<br />.-. _
<br />t P A.»(..,?. i yt'., ??° lJ?1I..i.}: REQUIREMENT SCI}#A AVG- DAIL..Y MIX i1GD s. :a r': t.!`s
<br />i., f . , :, SAMPLE #F ( 94 ? #• gi iF se . (?f ? #• Ez a ? ? ?
<br />..a
<br />-- t :t MEASUREMENT
<br />{?Ll%i ;
<br />V PERMIT K" #•a# h~tLAl,sl'.lNr 'Y '»? #•#•it#3f ?razh,7k3# r?-;# ;"i#- L?t^ :. 1;,aL,.3?•§i..-
<br />"F
<br />_t _t IEV k," 'REQUIREMENT r' nrS? ;? j a7u I ?Yt
<br /> SAMPLE
<br /> MEASUREMENT
<br /> PERMIT
<br /> REQUIREMENT
<br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were r TELEPHONE DATE
<br />
<br />?`" ""'}"i>
<br />,i/yy
<br />? prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information ?
<br />_
<br />?
<br />i ?
<br />T ! / 1 1,J r
<br />d f submitted. Based on my inquiry of the person or persons who manage the system,
<br /> ersons directly responsible for gathering the information, the information
<br />or those - ??-'I-••+"
<br />,,,?7
<br />i bk' ?%>A
<br />? t o yl 1
<br />?'i p
<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />IGNATURE OF PRINCIPAL EXECUTIVE r ?/ '?
<br />t
<br />IT 7
<br />TYPED OR PRINTED 1 am aware that there are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing violations.
<br />OFFICER OR AUTHORIZED AGENT AREA
<br />CODE
<br />NUMBER
<br />EAR
<br />MO
<br />DAY
<br />LUMMENTS AND EXPLANATION OF ANY VIULATIUN5 (Hererence an anacnmenis nere?
<br />3`I_ rT)lR S ) r:, s f....`r'?._ 3lz 3?' r'f^aa <' ra "t ;. 'v ?.. _ tt'ix': ii 0.t»`
<br />P AR ! y ?. s?? 7 }tall. J, ?t??i?e r_'.t1 r5' ?5 t °__ .?': .iP k l ? ..?i I I ; f"1.. ' >d'w . >. i'P t, ?; t ! ? ; , . .
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ; wi ;;.• . T?]I7i?'4rpat4Trn.
|