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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME 1+^? <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO , <br />J t ] WOO J Form Approved. <br />I (/V OMB No. 2040-0004 <br />? r, r._ _ JN? 3YC?QtR . <br />}r r-. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />::•. <br />3 <br />?.?? <br />-:'.'' <br />1 <br />It.IS?? <br /> MEASUREMENT <br /> PERMIT -, <br /> REQUIREMENT' <br /> SAMPLE U 1 ? r O GlpAi? <br />_ a MEASUREMENT <br /> PERMIT 77 <br />:,? _ _ •. ... ; _ :REQUIREMENT; _ <br />- SAMPLE <br />?. 1 <br />L© .1 r <br />Z/.:?,G <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE JC) <br /> MEASUREMENT <br /> PERMIT i y <br />_ _ . I , • REQUIREMENT' <br /> <br />. <br />_ <br />' SAMPLE - ...; . <br />COW <br />ILtG1 DI <br />.4t0 + <br />2 <br />Yi <br />^?3? <br />C-79 <br />: <br />: <br />r • ..% MEASUREMENT <br /> <br /> PERMIT .f <br /> REQUIREMENT <br /> <br />- SAMPLE .: <br />Y? <br />' <br />f? A <br />NtA <br /> MEASUREMENT T <br /> PERMIT -_...;.; K . - <br />_.._ - t. REQUIREMENT <br /> SAMPLE ®.®I?n ®•??! ' _., % /7( ,I 1rJS <br /> MEASUREMENT <br /> <br />PERMIT •. : 77-7 <br />. 'REQUIREMENT' " ` °• s <br />NAMEITITLE RINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />d <br />d <br />di <br />i <br />d <br />i <br />h <br />d <br />i <br />d r t TELEPHONE DATE <br /> <br />} ?? r °- <br />?%? ? prepare <br />un <br />er my <br />rection or supervision <br />n accor <br />ance w <br />t <br />a system <br />es <br />gne <br />to assure that qualified personnel properly gather and evaluate the information -- <br />?-..? <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 /> <br />v ?+^-•?•• <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />I <br />h <br />f <br />l <br />i <br />f <br />b <br />i <br />i <br />f <br />l <br />i <br />f <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE ) <br />ISO °( j <br />Y <br /> <br />TYPED OR PRINTED am aware t <br />icant pena <br />t <br />es <br />or su <br />m <br />tt <br />ng <br />a <br />se <br />n <br />ormat <br />on, <br />at there are signi <br />including the possibility of fine and imprisonment for knowing violations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATIUN OF ANY VIULAIIUNb (Heterence all attacnments here) <br />i <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 1C.1 ` z 'Thls%i$ -p =fbrln. PAGE tOF