Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Include Facility Namellixation if Different) <br />NAME <br />ADDRESS i,„j-i <br />FACILITY <br />LOCATION r <br />t1 i 7't ! i t wa t! C_:- ? t ,r, y t^ t t f r ,)? <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 TIC TO a` ;r <br />Form Approved. <br />OMB No. 2040-0004 <br />M i NOR N' <br />"3) B <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 />J1i.-.. AND SAMPLE 94) #z'•#"rKk <br />I SUAL MEASUREMENT <br />4 } ab L :; PERMIT -# # # Ft? rt 1 Y _Ei=< ## #;t,t ;?. °, t$ v?t# # ### W E Vtf 1' CSIJ L, <br />EFFLUENT `- A • _ REQUIREMENT '-N5"r MAX NO=:Q <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 /> <br />REQUIREMENT t <br /> <br />SAMPLE e <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 />ather and evaluate the information <br />ersonnel <br />ro <br />erl <br />to assure that <br />ualified <br />!? <br />• <br />?.? F,jf & TONY p <br />p <br />p <br />y g <br />q <br />submitted. Based on my inquiry of the person or persons who manage the system ? <br />.r <br /> , <br />or those persons directly responsible for gathering the information,' the informatio _.? <br />n `? <br /> <br />--- <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />EXECUTIVE <br />SIGNATURE OF PRINCIPAL / <br />I <br /> <br />TYPED OR PRIN ED I am aware that there are significant penalties for submitting false information, <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 />4 <br />,. COMMENT5 AND LAF'LANAIIVN Ut- ANT VIULAIIUNS (mererence all arracnmenrs nere) <br />("WAR'f•FRt.-f .',A PLIP•G & Pt'EPOiRI,T3:NG INSTRUCTIONS SEE S. C. 9: PAGE 9. OIL AND GREASE - SEE I. C. 15. <br />I ` <br />PAGE <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ?aO ] /CY O pay rrp• 1-3