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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION LL ' :# <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 ' TO • 1 <br />Form Approved. <br />OMB No. 2040-0004 <br />d+ <br />NOTE: Read Instructions before-.Cm- pleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />-. f` ., .. ., <br />_?'3_?,`•. <br />PERMIT .. <br />'F + REQUIREMENT a_ <br /> SAMPLE <br />i?,'k•.3°;,_ MEASUREMENT <br />DC., _,• _ - PERMIT. ;3 r? + .`r.l..3 JEa -t-„ <br />F... t :. REQUIREMENT t. t- <br />r.`_ SAMPLE <br />R; •IE•f MEASUREMENT <br />€T:;. }- PERMIT „ .... . # . :: - . ': _:. P 7..e , <br />„:; ;,.. , <br />1 7- <br />? .. REQUIREMENT <br /> <br />... •:° <br /> <br />n., , t? <br /> <br />:. - <br /> <br />e: <br />Ir <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; _,: <br /> <br />;.;. <br /> <br />I .. <br />> <br />"A p 3r??rt.'. <br />l <br /> <br />..i ar- :v REQUIREMENT f _ <br />a <br />is <br />i <br />x SAMPLE _ <br />1 (a`['r^ i`' _. MEASUREMENT <br /> PERMIT <br />.. . <br />it <br />t t :at' •? <br />i + <br />L 4 REQUIREMENT =9 f t '`' 7t . Y S , <br /> SAMPLE ! - .. :. .. 4 r <br /> MEASUREMENT <br /> PERMIT <br />rx :. <br />ti_ y. r ? REQUIREMENT <br />z i t' <br />1 is <br />':. SAMPLE <br /> MEASUREMENT <br />.• PERMIT s ; :- i s::, ;< ;, a{ •.. 3-k' <br />i 7" <br /> <br />??, _+.; <br /> <br />':r_iW <br />1 ; L,iM `zt t REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were <br />r <br />vi <br />d <br />d <br />di <br />ti <br />i <br />i <br />d <br />ith <br />t <br />d <br />i <br />d TELEPHONE DATE <br />_ k <br /> <br />? <br />eC <br />' <br />? <br />' p <br />epare <br />un <br />er my <br />rec <br />on or super <br />s <br />on <br />n accor <br />ance w <br />a sys <br />em <br />es <br />gne <br />to assure that qualified personnel properly gather and evaluate the information <br /> <br />Ill <br />,i <br />[•'I ? f' ?.? ? + <br />r e"A' ti,f <br />J ? submitted. Based on my inquiry of the person or persons who manage the system, f <br />? <br /> or those persons directly responsible for gathering the information, the information '"?'"^b""p `'? <br />•_+_'"' fJ <br />_ .e /a <br />f`_? <br />" I submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br /> <br />1 <br />n <br />w <br />th <br />nt <br />t th <br />i <br />ifi <br />lti <br />f <br />b <br />itti <br />f <br />l <br />i <br />f <br />ti <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE"' <br />R PRINTED a <br />a <br />are <br />a <br />ere are s <br />gn <br />ca <br />pena <br />es <br />or su <br />m <br />ng <br />a <br />se <br />n <br />orma <br />on, <br />i <br />l <br />di <br />th <br />ibilit <br />f ti <br />d i <br />i <br />f <br />k <br />i <br />i <br />l <br />i OFFICER OR AUTHORIZED AGENT ? A DAY <br />TYPED O nc <br />u <br />ng <br />e poss <br />y o <br />ne an <br />mpr <br />sonment <br />or <br />now <br />ng v <br />o <br />at <br />ons. _ ODE NUMBER YEAR MO <br />GUMMENTS ANU LAI'LNMAIIUIV Ur ANY VIUt_NIIUNa (mererence an arracnmenrs nere) <br />J i4 -7 <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. I , +Tbi? J ;a 4-p -fQrm. PAGE OF 7 <br />A S7 1 ,?