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PERMITTEE NAME/ADDRESS (include Facility Name/Locatioll if Different)
<br />NAME
<br />ADDRESS L j44 e
<br />FACILITY NAON11, n it
<br />LOCATION .
<br />,..,I.._;.?if s t P,:. is
<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 t TO LL-J `.
<br />Form Approved.
<br />OMB No. 2040-0004
<br />
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<br />NOTE: Read Instructions before comDletinci this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br /> MEASUREMENT
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<br />REPORT
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<br /> SAMPLE
<br /> MEASUREMENT
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<br /> REQUIREMENT
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER t certify order penalty of law that this document and all attachments were TELEPHONE DATE
<br />t prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel property gather and evaluate the information
<br /> submitted. Based on my inquiry of the person or persons who manage the system,
<br /> or those persons directly responsible for gathering the information, the information
<br />A
<br />1
<br />0`"
<br />'t submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />ATURE OF PRINCIPAL EXECUTIVE
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<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
<br />CODE NUMBER YEAR MO DAY
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<br />EPA Form 3320-1 Rev. 3/99) Previous editions may be used. t , rAt;t 10
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