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PERMITTEE NAME/ADDRESS (Include FacilityName/Location ifDiiferent) <br />NAME ?:t?F"'j. <br />ADDRESS la'i"aRl-.•;?,?.t sIi1'?•_ ? P Ji-.->?? r <br />: F_ : " <br />FACILITY <br />LOCATIONt:.ATE; 1f--, p c <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES Form Approved. <br />OMB No. 2040-0004 r + <br />DISCHARGE MONITORING REPORT (DMR) ., r 11-11 NOR <br /> <br /> <br /> PERMIT NUMBER DISCHARGE NUMBER - FINAL- 11 L S. <br /> k? F 3 F?i? 1 ;J xt:ifi( TO t_III`",5DEN CR <br /> MONITORING PERIOD <br /> YEAR MO DAY YEAR MO <br />a DAY <br />^ t?Fr' <br />;; <br />i`10 DSSt: <br />I > > # <br />FROM TO . : <br />, <br /> NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />.Yr'wP< Iw% :r'.I''. ,.,z--.' <br />SAMPLE !#jl.?(# i:rr s?31 if##?£7} <br />DISEIrC IAUL.) MEASUREMENT <br />007) - . , C, <br />PERMIT Ike # # ? # #= st t # st '? i# it # 3F { tv <br />FFL.UE,NT 4_ =4r:)SS ` ia'-_UE REQUIREMENT it r # 30DA AVG DAILY FIX MG/[_ MONTH <br />. . <br />)ra= ° :_ s"-: <br />SAMPLE <br />n ii# of <br />#3F#ii3i# <br />##st# <br />Ceti) <br />Cr?S E).7 MEASUREMENT <br />01.1".1 41 PERMIT ?'?'? _ ## # i s##'? ?d ## sES£ 3#3r3t iQ L <br />FF(_.J..JENT GROSS VAL.UE REQUIREMENT , irsrit 30DA DAILY MX UG/L MONTH <br />DI SRl%+'•f ?r: SAMPLE ¢#3r# sF f : a #o-t #} # sra't cf t <br />iF MEASUREMENT <br />f41r PERMIT YI#:## #x#3}# 11 3E## y <br />EFFL.Ijj`-" •I,•• t_RIJ;-55 VALUE REQUIREMENT tz ?? 30DA lA`;G DAILY MX PIG/L_ MONTH <br /> SAMPLE r #yF r A # #ii # Ti a z t e_ 1 <br />TOTH=_ .Fil~C0--VEF<A2LE MEASUREMENT <br /> PERMIT # 3f _ st if 2f # tf z ## ii it 3t <br />REFUR <br /> <br />t, <br />EFFLUEN ?ROS:5 Vea" Ur REQUIREMENT # 30Dfi AVG DAILY MX UG L MONTH <br />r. <br />;....E t•,L <br />SAMPLE .} # dl..• 3F # a4 .;..... s..;}. •if # -• # `?t• •'.f• t 1 <br />TOTA'RE•rQ-'v`EPA,1_4' E MEASUREMENT <br />Csl L' ?: = -t PERMIT <br />'##' ?i# <br />##### # <br />## <br />it3Pi?3t # <br />EFFLU-r,!'r t R0S13 VALUE REQUIREMENT d ?### 30DA f1 VG DAILY MX UG: L. MONTH <br /> <br />JAF£E;ilt:i•J%lr =li._ RFC[. SAMPLE # :?°rsE ?ra}ia? #3s?tit <br />VERAB i_F MEASUREMENT <br />)1Ic.'3 {') PERMIT ### •'.## ?!#• *** it• 3F## <br />EFFLUENT GROSS VALUE REQUIREMENT 30DA A-VG DAILY MX UG/L MONTH <br />C r ..G'? i %• t..J! ! ? t '( ,r '<... I~ ? d SAMPLE <br />TOTAL RECOVERABLE MEASUREMENT <br /> PERMIT ## ' Yi # t sF ## # r# i <br />EFFLUENT C-RO 35 VALUE REQUIREMENT 3QDA t1 VG DAILY MX UG/ L MONTH <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHO NE DATE <br /> prepared under my direction or supervision in accordance with a system designed ?.-- • - - <br /> <br />?f r-t ? 125 ?` <br />t <br />120 <br />to assure that qualified personnel properly gather and evaluate the information <br />stem <br />erson or <br />ersons who mana <br />e the s <br />in <br />uir <br />f the <br />itt <br />d <br />B <br />d <br />b <br />/ , <br />p <br />g <br />y <br />q <br />p <br />m <br />e <br />. <br />ase <br />on my <br />y o <br />su <br />the information <br />ersons directly responsible for gathering the information <br />or those <br /> <br />V <br /> <br />r <br /> <br />i?1 V ?(?1?E ?lt? <br />c , <br />p <br />submitted is, to the best of my knowledge and belief, true, accurate, and complete. <br />ISIGNATU?jE OF P INCIPAL EXECUTIVE /f 07-- f <br />? I am aware that there are significant penalties for submitting false information, ?OF?16ER OR-A THORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLAI IUNb (Hererence an arracnments nere) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 0 0 0 41 /0 700 4-4V710(form• PAGE ? OF