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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME t'; P. <br />ADDRESS t=}lyE LtjIND PR7J€ C F' <br />FACILITY iLr_y <br />LOCCATION _-F, ri ?Eo,', t 1 4 ? t ?? <br />`?: t r E f ' P7 F G' <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />OMB N&'2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) I'i I NOR ? <br />PERMIT NUMBER DISCHARGE NUMBER 1 - F I t?fA_ <br />MONITORING PERIOD <br />YEA MO DAY YEAR MR. DAY <br />FROM ;. ?. TO x . u If NO 0ISCIHARGE <br />NOTE: Read Instructions before completing this form. <br />PARAMETER 4 QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE #t: iF f 4: f=1 r' <br />IMFPHIAI: ES C=FOiN1C MEASUREMENT <br />i ,.: PERMIT f F t # st -i; CE ii iY I s :: R , HF'tNC T <br />EE t i 3F=1_w'l REQUIREMENT A x n. PIN VALVE TCIXC:T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT rt <br /> ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> IR <br /> REQU <br />EMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />L r• <br /> REQUIREMENT s ? w <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ <br /> REQUIREMENT ^w <br /> SAMPLE <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 TELEPHON E DATE <br /> <br />4 C_(Z <br />A prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the information <br />_ <br />, <br />0 <br />L-- submitted. Based on my inquiry of the person or persons who manage the system, ` <br /> or those persons directly responsible for gathering the information, the information <br />I Al F-C z <br />&-/Aj V E ti ? submitted is <br />to the best of my knowledge and belief <br />true <br />accurate <br />and complete / L (J <br />r , <br />, <br />, <br />. <br />, <br />I am aware th <br />t there are significant <br />enalties for submittin <br />false information SIGNATURE OF PRINCIPAL EX CUTIVE <br /> p <br />g <br />, <br />a dFFIGER'R AUTHORIZED AGENT AREA <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. CODE NUMBER YEAR MO DAY <br />COMMENT5 AND hAPLANAI IUN UI- ANY VIVLAI IVNb (rtererence an arracnmenrs nere) <br />FOR lam 3F?}:t OF TES fT €?PC3CEL?UE=. ft?"P L_?7l?JE:t-"1 % AT WHICH STATISTICALLY ??IG1tiiIF [?It°F' <br />;. -, f1F PER!,! <br />BETW0:k! !EST Z! CONT U SIN CODE "c". RP'i° IC25 USING CODE "P". ATTACH CHIRON I-OX TEST FRPT TO DMR, <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. AGE raA F <br />00230 / 0 '1??`1? ,%-41p-d30)nT1. P