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PARAMETER
<br />- QUANTITY OR LOADING
<br />QUALITY OR CONCENTRATION
<br />No.
<br />EX
<br />FREQUENCY
<br />OF
<br />ANALYSIS
<br />SAMPLE
<br />TYPE
<br />AVERAGE
<br />MAXIMUM
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<br />MINIMUM
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
<br />1 certif under penalty of law that this document and all attachments were
<br />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 />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 />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />I am aware that there are significant penalties for submitting false information,
<br />including the possibility of fine and imprisonment for knowing N iolations.
<br />.
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<br />TELEPHONE
<br />DATE
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<br />SIGNATU OF PFIINGIPAL E ECU TIVE
<br />( -OFF ER OR AUTHORIZED AGENT
<br />REA
<br />CODE
<br />NUMBER
<br />• .
<br />YEAR
<br />MO
<br />DAY
<br />TYPED OR PRINTED
<br />I I PERMITTEE NAME/ADDRESS (Include Facility Name/Location f Different)
<br />NAME
<br />ADDRESS
<br />•
<br />FACILITY
<br />LOCATION .
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.
<br />Cr'
<br />cc a: =•22
<br />FROM
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEMJNPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER
<br />YEAR
<br />MONITORING PERIOD
<br />MO DAY YEAR
<br />TO
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
<br />:2— C. F
<br />O .1 A
<br />DISCHARGE NUMBER
<br />MO
<br />DAY
<br />Form Approved.
<br />OMB No. 2040-0004 %,
<br />F7231 7
<br />C: ,
<br />NOTE: Read Instructions before completing this form.
<br />J!._
<br />4 . - P4LX9r 113 .
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