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PERM ITTEE NAME/ADDRESS (Include FacilityName/Location ifDierent) <br />NAME t: <br />ADDRESS z R"?_.1 1"I`:ID F r; .. .. <br />FACILITY : , - <br />LOCATION;_rs <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) rt I;iri OMB No. 2040-0004 + <br />PERMIT NUMBER DISCHARGE NUMBER !'il::`3A <br />MONITORING PERIOD ?Nl :: <br />YEAR MO DAY YEAR O DAY --- <br />FROM TO <br /> NOTE: Read Instructions bef ore co mpleting thi s form. <br /> PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br />f AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS TYPE <br /> <br /> <br />i <br />- } • '- ' • l ' SAMPLE <br />MEASUREMENT <br /> C L r K <br /># ,.. 1 <br />F** IT } <br />r r <br /> PERMIT <br />REQUIREMENT ( <br />t-W vt-1-U, . x: <br />.? x t h r sx t , 1 -, <br />` <br /> SAMPLE <br />MEASUREMENT 4, <br /> E <br />M <br /> P <br />R <br />IT <br />REQUIREMENT <br />s <br /> <br /> SAMPLE <br />MEASUREMENT - <br /> PE <br /> RMIT <br />REQUIREMENT <br />_ <br /> <br /> SAMPLE <br />MEASUREMENT <br /> PE <br /> RMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br />MEASUREMENT <br /> PE -° <br /> RMIT <br />REQUIREMENT <br />:r <br /> SAMPLE <br /> <br />` <br />MEASUREMENT <br />* - <br />• <br /> PER <br />I <br /> M <br />T <br />REQUIREMENT l <br /> SAMPLE <br /> MEASUREMENT Y+ <br /> PERMI <br /> T <br />REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penaltytf law that this document and all attachments were TELEPHONE DATE <br />_ prepared under my direction or supervision in accordance with a system designed <br />f a `LI 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 direbtly responsible for gathering the information, the information <br />rv v ,I <br />r `r 1 F -: ?? submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />I am aware that there are significant penalties for submitting false information, <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br />CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />i? 7- <br />?, : l: i z t C r x r <br />i v F_ I,: ,-L <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ?'1 1Q? 9r I i. PAGE <<-y OF,. -?