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PERMITTEE NAME/ADDRESS (Include Facility Name/Location lfDifferent)
<br />NAME M .X N . l dG
<br />ADDRESS E D li-
<br />7 r,; ;I F S
<br />FACILITY
<br />LOCATION
<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004
<br />DISCHARGE MONITORING REPORT (DMR) M 1! .I ..<. r ` ,G f:1 •,:+a:f u"'"', t ,Z,ii tl?>•i s./s-r 3
<br />PERMIT NUMBER DISCHARGE NUMBER [1 `lT I
<br />Fa i_ >_,t.=_ s F 7. 1 T ROL) T" Cs?EE
<br />MONITORING PERIOD
<br />YEAR MO DAY
<br />1 -7 YEAR MO DAY +=. -,
<br />FROM t i•± w TO _tt_,
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO,
<br />
<br />EX FREQUENCY
<br />OF
<br />ANALYSIS SAMPLE.
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<br />TYPE
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<br />REQUIREMENT 1. 2
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<br />.3:10D i t? +G REPORT
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<br />NAMENITLE PRINCIPAL EXECUTIVE OFFICER l certify under penalty of h.., that this document and all attachments were TELEPHON E DATE
<br /> prepared under my direction or supervision in accordance with a system designed -
<br />
<br />V Cj"Pw ?? to assure that qualified pek onnel 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 />onsible for gathering the information
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<br />submitted is, to the best of7ny knowledge and belief, true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE O
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<br />VV v f am aware that there are Significant penalties for submitting false information, T AREA -
<br />
<br />TYPED OR PRINTED including the of fine and imprisonment for knowing violations.
<br />g possibility g OFFICER OR AUTHORIZED AGEN
<br />CODE NUMBER YEAR MO DAY
<br />
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />SET -1 WILL BE WAIVED FOR - I0YF, 24HR PRECIP EVEJ\ _ SEA'. I. A. 2, PG. 4 FOR REQUIREMENTS.
<br />wrPL'r l}ys ?..I }tlfw INSTRUCTIONS - 1. It. 10', PG. 9.
<br />001 151:OTh-j?isy'i?a 4-?&5firil. PAGE IOF`
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. t
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