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<br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location iitDijjerent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) - Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) bR 1. {. ; ti OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER" 1 (;`.?; t ~;s'
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS TYPE
<br /> SAMPLE t 31 . ,. . Y ;
<br /> MEASUREMENT -
<br /> PERMIT #?r sF :- :? x ?,r ,y E sr : : ra- . >t t r -..
<br /> REQUIREMENT
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<br />PERMIT 74- -F 7-7F'T-177
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty,ef law that this document and all attachments were - ---.y T ELEPHON E DA TE
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<br />71 prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel
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<br />tted. 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
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<br /> submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />I SIGNATURE OF PRINCIPAL EXECUTIVE I (I / r?; r t 4 '
<br /> am aware that there are significant penalties for submitting false information, `
<br />
<br />TYPED OR PRINTED
<br />including the possibility of fine and imprisonment for knowing violations.
<br />OFFICER OR AUTHORIZED AGENT AEA
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<br />NUMBER
<br />YEAR
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<br />l?/1RA11ACA1TC AKIn CVDI Ad1AT1e%KJ AC AK1V \11/11
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.,.': t :":'I'?1151S ti 4?p$1LOITTl. PAGE ??, OF
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