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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME P_ IF", t.,, { t?
<br />ADDRESS I"r I=' R DJ E-C- _F
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM if! TO s. <
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE. Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO,
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<br />EX FREQUENCY
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />S VALUF REQUIREMENT `r I I X
<br />NAMENITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were
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<br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT O
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<br />w COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. t1 -70 t"tUis,,ist a 4-pa ?b ©rrri. PAGE ?T OF
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