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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION ? ; , 4 <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />- ._ .Y ^j r-,. -F <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO , ? <br />-TL NOTE: Read instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />i- SAMPLE <br />J^T <br />l I f IN J 17'J <br /> MEASUREMENT <br /> PERMIT <br />Y_i7- ) REQUIREMENT r <br /> SAMPLE r# ; . i ., r <br />? ( 1 `i? <br />G-eAg <br /> MEASUREMENT •, <br />_ PERMIT : <br />- 7 s REQUIREMENT +f??t;r 7u A`,' <br />l <br />t.- .. <br />,.... _. _ . SAMPLE <br />T eA3 <br /> MEASUREMEN <br /> PERMIT `R1 <br /> REQUIREMENT AV" ; T;- y N'Tf <br /> <br />` SAMPLE ..v _- . . ^: t is p <br />, .. ;:; MEASUREMENT <br />r,"• 'F, PERMIT ; .>. - .:.< ; •. <br />h?.': i' e E_ • i_._. , - ?; ,.:. "x : ;. _,,; : REQUIREMENT'.: AV G 1) ?-4 I: r._.Y r•; ?- .,: ?:" •ri MONTH <br /> SAMPLE _ ^•? <br />x}90-0 <br />G? ?S <br /> MEASUREMENT <br /> PERMIT <br />..: r :; .. - k ...., .; '..: _ 700 t .. __ a x_: <br />r ? - REQUIREfJIENT' N ; r V(? 1t r I "13 4. ..° s.w MONTH <br /> SAMPLE .,,;- rj( <br />NjA <br />01A <br /> MEASUREMENT <br /> PERMIT t st , o. : tt? o x ; <br />yYl, REQUIREMENT <br /> <br />i", , SAMPLE <br />C.U + <br />G1 O I x - <br />Q? 1 <br />(? <br />INS1 <br />',,i MEASUREMENT <br />':.;C _. .. ., PERMIT <br />i.. ... <br />z <br />7? ..... <br />-.. <br />r? <br />s <br />i ..f x <br />c , - <br />?'F ?' '.i... REQUIREMENT <br />s`P;. <br />. <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty-of law that this document and all attachments were <br />d <br />d <br />die <br />ti <br />i <br />i <br />i <br />d <br />ith <br />t <br />m desi <br />n <br />d * TELEPHON E DATE <br /> prepare <br />un <br />er my <br />ec <br />on or superv <br />s <br />on <br />n accor <br />ance w <br />a sys <br />e <br />g <br />e <br />??? I pAt??2 i D f <br />ri'• to assure that qualified personnel properly gather and evaluate the information <br />submitted. Based on my inquiry of the person or persons who manage the system, <br />t <br />?.r+ or those persons directly responsible for gathering the information, the information <br />V , ^ C ?? tI D lY <br />1:? J <br />1 submitted is <br />to the best of my knowledge and belief <br />true <br />accurate <br />and complete. o U 7 <br />01) 7 <br />2 <br />K+ , <br />, <br />, <br />, <br />th <br />t th <br />ifi <br />t <br />lti <br />b <br />itti <br />f <br />l <br />i <br />f <br />ti <br />I <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE ? - - <br />- <br /> am aware <br />gn <br />can <br />pena <br />es <br />or su <br />m <br />ng <br />a <br />se <br />n <br />orma <br />on, <br />a <br />ere are s OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. I <br />CODE NUMBER YEAR MO DAY <br />COMMtNTS AND EXPLANAIIUN Ut- ANY VIULAIIUNS (Hererence all affacnmefltS flare) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. <br /> <br />PAGE .19F <br />Ctv?' ;THa^s- gyA4-:pa&f©Tm.