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PERMITTEE NAME/ADDRESS (Include Facility Name/Location iitDii ferent) <br />NAME <br />t <br />ADDRESS <br /> <br /> J. 4 ;:2 3 <br />FACILITY <br /> <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY I YEAR MO DAY <br />FROM "' . TO '-- a <br />MINOR <br />Bu BF, 0 V! <br />-- F NAL_ <br />T I, T-1.1 <br />Form Approved. <br />OMB No. 2040-0004 <br />f <br />mEE3 i <br />NOTF- Road Instrllr_tinns hafnra emmnlptinn this fnrm_ <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />A <br />SAMPLE 74 -4- <br /> <br />: -- <br />i"-C4 %. MEASUREMENT <br />4, !° ` `, <br />PERMIT ';' r # ?E tl 3# t[ ?e 3E xF t L#CC i f;. '_ <br />E'FFL_C!?'%tiI' _-i CSIS {. ?.L_UT:. REQUIREMENT ZJr; Ac'` i`tJ; L.Y MX i?fG/i MONTH <br />F} -J. I .'. SAMPLE q 1 x# t- r-757 <br />f <br />s: ty`,,' } MEASUREMENT <br />=1 f. <br />PERMIT > ?#°f### #: n # if 3ssi # r# O NCE-,, r n <br />~FFL}F:? <br />,-; .;Y :;S JrL.UE: REQUIREMENT r.. AGE t?; A VG DAILY MX UG/L. NTH <br />'s V tK L.?P,% - SAMPLE tt r a i n 5# b zr ## l <br />L'.'=f L } MEASUREMENT <br /> <br />-' <br />PERMIT ##icir <br />41- if #:rx <br />-4 sf# <br />s .. <br />>~.FFL_i1,:_f <br />% REQUIREMENT <br />' ` •:# C}CJA Aki?x DAILY M i i t's"I MONTH <br /> SAMPLE 'r#?'.#:?•:k ? ?•'}?•:?• ;?-ir:s3r-:-:+ ,? t G J <br />TO TAI- F lt i<; AB L F MEASUREMENT <br /> PERMIT <br />EFFL_UEr--l- `_,'"t •`. E'A;....IJi', REQUIREMENT 30 <br />fttu?"w <br />DAILY MX <br />l 1:i._ <br />MONTH <br />S. F.AV SAMPLE <br />TOTF:Ltri.?.0 `vtir.RA2L E MEASUREMENT ?i <br />i <br /> PERMIT ?F i##4E #:t f#3I #X# 3F f#3i#3t ; <br />EFFi,._IJ10 I T G;"'?0 S VALUE` REQUIREMENT r#•?3 30 AVG DA Ii_Y MX UGC/L_ MONTH <br />Jty",j r' ;.. ..: fA' F". E.. .. {., <br />SAMPLE ..d..;t•?it .?f..sr''?" ft-":'SS' 'jI••#••?(•t-. <br />VERIA3L_E MEASUREMENT <br />-2 <br />PERMIT <br /># #it # <br />b# s! # <br />## <br />9d 3tF <br />t <br />EFF L_UE iT C'ROS5 VA1_UF REQUIREMENT 36DA AVG DAILY MX UG/i.,.. MONTH <br />:1"i.YE t F ; 4?{,,:. ) ?,.° i, i <br />SAMPLE t }t?f'#?{ t : ## i # 3E 7i t. <br /> <br />d' tl <br />TOTAL P1--- C'0'-VF+?A5L IF MEASUREMENT, <br />`• . PERMIT %ra it it s4 3t iE t w# x't ac ' # # it ur, 1= Cis <br />EFi`L.IFiw'''r %i f l?jVAL I TZ REQUIREMENT QTIA f {?7 t1li t° MA` IaG:+L MONTH <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br />57t' PN €-?? p q ?17?,LJ `1 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 /> <br />/ <br />submitted. Based on my inquiry of the person or persons who manage the system, <br />or those <br />ersons directl <br />res <br />onsible for <br />atherin <br />the information <br />th <br />inf <br />ti .. <br /> <br />?7 t V F AJ T p <br />y <br />p <br />g <br />g <br />, <br />orma <br />e <br />on <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />I a <br />th <br />t th <br />i <br />if <br />t <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 />?/ <br />?j <br />_'-_-_TYtU OR PRINTED <br />1 VI'( m aware <br />a <br />ere are s <br />gn <br />ican <br />pena <br />t <br />es <br />or su <br />m <br />ng <br />a <br />se <br />n <br />ormat <br />tt <br />on, <br />including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT T <br />141 <br />jr- AR" <br />CODE NUMBER YEAR MOil .,_DAY <br />VVIVlm G171J NIYV cnr Lf .l -.1v1. yr -.M I VlwU I IVl`'J In010101it.= 411 O1Kni11fI1011LJ ulure] <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. uL}c f?(;_4 PAGE OF 1