|
PERMITTEE NAME/ADDRESS (Include Facility Name/Location ifDierent)
<br />NAME
<br />ADDRESS
<br />FACILITY !?r"3 r L'.,..:'
<br />LOCATION H
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM TO
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
<br />PH SAMPLE
<br /> MEASUREMENT u
<br />'7C?
<br />1 PERMIT # l? k? 4 t: T!` T:
<br />C. t.
<br />t
<br />s.:.?" f._'.???1 ! 'T.l r^ t zv r. ?. Lf??
<br />
<br />F E, REQUIREMENT .. h T
<br />;fi
<br />)•#t MUM
<br />` .t °'. ..is
<br />M^3. i t.:, SAMPLE f: 9s. is -. ,. t t
<br />/s
<br />,
<br />t
<br />
<br />'
<br />S
<br />}`,`
<br />aer?
<br />D"T
<br />'E MEASUREMENT ~f `,
<br />) ?v?r
<br />.
<br />:
<br />_.
<br />. PERMIT -k? TT -A
<br />v+ I "
<br />T t
<br />
<br />t_.U r.i') s xitI.;.r'a i?_
<br />EFF
<br />REQUIREMENT
<br />;.9?t €s
<br />(r7'? r" 1
<br />li,.rr•, ?}
<br />ej4't., SAMPLE
<br />MEASUREMENT ! r t '? <?? t
<br />
<br />-
<br />. O .iti PERMIT 1r lr i# iE #r ,..: ?z. I# #.ti; fi 1 ?r W sa t'; k 3 +- ,t: 7 73x
<br />TN
<br />r,
<br />
<br />EF'F f?t3.P+1 , l D5,3
<br />
<br />REQUIREMENT r 2. 5 A A y ;,; DPI, ,#. #.. 'i i#p .
<br />
<br />.
<br />
<br />; .
<br />fit r
<br />
<br />Rt:, r--,RA;l>L. E
<br />TOTrhi SAMPLE
<br />MEASUREMENT
<br />t .
<br />h
<br />, . e .
<br />Z-•'`
<br />/,°fJl
<br />I?V C.
<br />... PERMIT Yi xc i h t ?i •i ? is ti ?: yi..? . . y. kss . dt t,l 3i, hs 3i is 44 1 1 ! y C ' 1"
<br />F L.l1t"."+i f `Jhif..Ul' REQUIREMENT f,
<br />..
<br />30 N AVG
<br /> SAMPLE i. 5: R- ;i v ,4P.
<br />i i A
<br /> MEASUREMENT
<br />ry ; _>L'.w
<br />PERMIT :,;
<br />4 IX
<br />'
<br />i.i
<br />! "i.. Jw6L I . _+ . V--,;., OF REQUIREMENT s ... ,
<br />D14 s. #_
<br />y I i
<br />.
<br />
<br />-k lui
<br />T--LC! F .:. _f t.. t (`,...
<br />
<br />
<br />t t tia, ..i
<br />l3 S i..n . ri
<br />6d
<br />SAMPLE
<br />MEASUREMENT •, f . n r., 03 T
<br />s?•.R•sr•ir.t:.?;
<br />•t- ri# ,..,tz..a-
<br />.?.
<br />iti• °t z.t;..
<br />^?
<br />l ..
<br />• ' I (sf fc3r 4t kF•#. st tc # k it i i3 i..z : -i ! i i i_ti.ll,
<br />
<br />t<f?tl_.k#t..:
<br />
<br />N T st: ,_a._ a .f-..
<br />),H F rk, (..t d PERMIT
<br />REQUIREMENT
<br />,
<br />y?
<br />30D A A VG
<br />i
<br />
<br />s; r
<br />I e
<br />$_«?.,
<br />
<br />-l
<br />R3C'; . tl; t SAMPLE st s?k<F '3r _.,< • i> " ,
<br />
<br />?
<br />
<br />?
<br />V'!:-:
<br />1) X
<br />3? SOL MEASUREMENT ? U l J ? ?, r r l+
<br />?
<br />..
<br />,
<br />70e' PERMIT
<br />#i #tE
<br />'RS; s x t
<br />'n t°14•
<br />'#t
<br />.i
<br />/ 1 ,;L
<br />
<br />•r
<br />Fr i. UENI * c f v'Al_W: REQUIREMENT 30DA A,tV(3'' Dol?,a a 'f' MIX I { :.
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHO NE DATE
<br /> 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 /> submitted. Based on my inquiry of the person or persons who manage the system,
<br />the information
<br />the information
<br />atherin
<br />nsible for
<br />di
<br />tl
<br />h
<br /> ,
<br />g
<br />g
<br />rec
<br />y respo
<br />or t
<br />ose persons
<br />l
<br />d r
<br /> ete.
<br />comp
<br />submitted is, to the best of my knowledge and belief, true, accurate, an SIGNATURE OF PRIN AL EXECUTIVE t
<br /> I am aware that there are significant penalties for submitting false information, OFFICER OR AUT RIZED AGENT AREA
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. CODE
<br />COMMENTS AND EXPLANAI IUN VI- ANY VIULAI wN, Itte?erence an auacnrnenw 11crn1 } }_ v ??
<br />a. . c: ?. r C .) . t t?J E 1 1 F µ Z- 3 i l i{ 7 i_ ? 0 c T . L. 0 t 'ti R .T.':, t t I E ?F F ., _i
<br />t)R 1 - Yi?t i?!^? TF ti"! i. t ;. Ii, i #'3 1' # ( `"'. zt1 1. #..r 1 T t- i 11a. 4 ;:Ii kt€t4 tr#) ?rI )t`•; _, r :,..r,.
<br />PART 1, 6 ANY ADD I D"..' PAGE
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. `iy1?'icQ 4,ipp arm, E OF
|