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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS J 0!x E. NO, <br />FACILITY <br />LOCATION }firr <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY + a {e' <br />FROM TO iti,• ?. R.'; <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX ALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS AN <br /> SAMPLE • t }: +. r. t as I • ~ k i <br /> <br /> MEASUREMENT <br />, <br />1 <br />) PERMIT :.< •} 3? p t5 : > ty sr 1 Ca r .,s{,;, 9j0 i ir}"• r l"'4ti3 <br />, <br />( <br />c <br />( REQUIREMENT <br />r <br />: .. <br />s 'i 1 { :L h.tiai`' _ Mii' i <br />a SAMPLE <br /> <br />MEASUREMENT ? r . t; . ;• . 4 k rr # s: <br />h . <br />?I j + R } tS=L7 ? <br /> PERMIT <br />x:°s .,.n:. <br />sr. 7 a: k s I` <br />tS # <br />.#. <br />,,t <br />e€i <br />VI1LJ <br />kCA1x <br />? ;" L <br />t <br />wy <br />' REQUIREMENT s 1Y l s Fi r° <br />i <br />-4 it „` V ' r. I°?I II? 3?H <br />I <br />1 Ci <br />111w"ke t t ia <br />?-lic; VI tir . <br /> i ii E: <br />3 Wt `' S <br />` ?. 1..a ft R;._ SAMPLE h_ . "M -K t :.: ........ ..... <br /> MEASUREMENT <br />= 0 O PERMIT ti s, ?' it -t k St?~ if R EFS.?z" T 0 5 fi <br />_ <br />RAT <br />r F: ! e \j f, Fi ! f; REQUIREMENT is 2-C)Dl § <br />r <br />;ibL SAMPLE <br />t •. <br />, <br />a• MEASUREMENT <br /> PERMIT iE # 5t} r k sI 3t r < s x .r s 3S?.! <br /> <br />NT t" t".r ?c t t: REQUIREMENT <br />J.?' SAMPLE <br />S-:i <br />` MEASUREMENT <br />? ?p c c <br />C tR' H 7 Fel EN. FL- AN, <br /> <br />S <br />' <br />PERMIT <br />Fr:Pi ; <br />R P#.".•'s(•~,t 3 <br />.. t ?• •? ?• ?• <br />s ,. t? re <br />- <br />OF <br />D <br />d V I <br />REQUIREMENT . <br />MX <br /> <br />;; <br />N, -, <br /> <br />. ;..•;. <br /> <br />t.i p_., <br /> SAMPLE 11GIz i. .: ? ( 514 3 ri <br /> MEASUREMENT <br />LliL. I I ? <br /># PERMIT ifr' k#? ii fi ) i r Y F a= f... . i3E r i .. #. s:• ; s# t <br />ti. E' <br />, <br />' <br />a <br />+ <br />` REQUIREMENT i M: s. 4iCS? '6ti) <br />v+ <br />r! ? <br />i <br />5?i <br />x .t.IrW <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />XECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br />NAMEI TITLE PRINCIPAL E 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 />e ( ! / // 7 7 ?{ submitted. Based on my inquiry of the person or persons who manage the system, ° <br /> the information, the information <br />atherin <br />onsible for <br />tl <br />di <br /> g <br />g <br />y resp <br />rec <br />or those persons <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />SIGN TUR OF PRINCIPAL EXECUTIVE <br />,_• <br />C ' <br />19 I am aware that there are significant penalties for submitting false information, OFFICER OR AUTHORIZED AGENT NUMBER Y MO DAY <br /> ossibility of fine and imprisonment for knowing violations. <br />th <br />l <br />di <br />i CODE <br />TYPED OR PRINTED e p <br />nc <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLAIIUN, (Ffererence au duecnntertw na,vi <br />• <br />` KK <br />t R31 <br />e S.« t,_.~ 6 S t' , r \?#- L 5'I f t" rt..... ?:.74?;? :t? S. •irZ <br />TO ? s <br />3 <br />., .. ?,? ixtt" ? #l?'"" ? ;•Y ?='t tE ?.:? ?t t,i-fe ...? ?'_ a..? ., as . f. t; __.... .d 1 4 <br />TT f v <br />PART ANY Y r MS ?, [ T' 1 i. <br />y fit) trsF YM '? T4 ,qrm. PAGE IOF <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.