Laserfiche WebLink
PERM ITTEE NAME/ADDRESS (Include Facility Name/LocationiifDierent) <br />NAME ' <br />ADDRESS' `""( - j r lit H }? <br />FACILITY .y <br />LOCATION?. A r fi. <br />q ' <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)- Form Approved. jr <br />DISCHARGE MONITORING REPORT DMR OMB No. 2040-0004 <br />PERMIT NUMBER DISCHARGE NUMBER F `L,. ?"i?Mr>+q <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY, <br />FROM TO <br />._ .. t : <br /> <br />PARAMETER <br />r QUANTITY OR LOADING ?vw 1 v.. neau utsTrucuons oeT <br />QUALITY OR CONCENTRATION ore co <br />NO. mpleting tnl <br />FREQUENCY <br />OF s Corm. <br />SAMPLE <br /> AVEF(AGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> <br /> <br />x'k1F `7HA F- <br />SAMPLE <br />MEASUREMENT k..x .;:. <br /> <br /> <br />;..":i'A' PERMIT <br />REQUIREMENT <br />Y <br />y <br />. <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />t <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />r <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 /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE O FFICER 1 certify under penaltyef law that this document and all attachments were T ELEPHON <br /> <br />prepared under my direction or supervision in accordance with a system designed E DA TE <br />L I (r L. <br />' <br />` <br />I <br />/ to assure that qualified personnel properly 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 /> <br />i <br /> <br />y <br />1 <br />) submitted is, to the best of my knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED I am aware that there are significant penalties for submitting false information, <br /> <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOL <br />including the possibility of fine and imprisonment for knowing violations. <br />ATIONS /Rafprpnrra all a}iarhmanfc do?em OFFICER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />i <br />b •` W t t m "' <br />i <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ` ' - !• „ ThiS? 1§` $'4x X21 ` OIITl. PAGE OF<7