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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS t,?i I , R! a Y,z1 t ?! <br />FACILITY `I <br />LOCATION . <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. p <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />IPERMIT NUM <br />BER DISCHARGE NUMBER gr •^ ; ? r <br />r ... „ <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM i.J TO <br />- = NOTE: Read Instructions before-completing this form. <br /> PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> <br /> SAMPLE <br />MEASUREMENT 3; ?s .,, s r • .M1 <br /> r <br />-1' <br /> , <br /> <br />wrt Il,_t,l ;?-v.!t'.-nrc v?!: q'- <br />PERMIT <br />REQUIREMENT'. <br /> <br /> <br />"F3 <br /> <br /> <br />- <br /> <br /> <br />? f it <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> <br />i SAMPLE <br /> <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> PERM <br />T ° <br /> I <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> PE <br /> RMIT <br />REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty-of law that this document and all attachments were prepared under my diniclion or supervision in accordance with a system <br /> designed TELEPHONE DATE <br />to assure that qualified personnel properly gather and evaluate the information <br />/'?`T"- FP /,(_ ?, ?]j, submitted. Based on my inquirv of the person or persons who manage the system, it <br />_ or those persons directly responsible for gathering the information, the information <br />R E-212 /7 submitted is, to the best of my knowledge and belief, true, accurate, and complete. r- <br />f am aware that there are significant penalties for submitting false information, SIGNATURE OF PRINCIPAL EXECUTIVE it !/ Lt ! <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODEAREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) , <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This -is, a.4-pt-fvrm. PAGE OF <br />- t'