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<br />PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME ,. <br />ADDRESS <br />FACILITY <br />LOCATION <br />f i•' ( j r/) Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) M f ! ! ?U OMB NO. 2040-0004 <br />DISCHARGE MONITORING REPORT (D R) 1 <br />~ PERMIT NUMBER DISCHARGE NUMBER t <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 NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE r . ,i. •,p .; . , ,, .. , <br />CIS <br /> MEASUREMENT <br /> PERMIT <br />r <br />r <br />_ <br /> REQUIREMENT -k <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of 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 to assure that qualified personnel properly gather and evaluate the information <br />i• <br /> <br />1 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 />-?- s• <br />'"i!t Q? <br />i" 3 ,?^ <br />as <br /> <br />t ; l <br />_ <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />S <br />IL/' , <br />CJ <br /> I am aware that there are significant penalties for submitting false information, AREA <br />RINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />TYPED OR P <br />COMMENTS AND EXPLANAI IUN yr ANY vlv?E+1 tvt?a (rsrtrrr nr c alt auae nnicn?a nc?cL <br />12 <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. PAGE OF