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PERMITTEE NAME/ADDRESS ()ncirlsFarWeyN?w?Laeation (JDIQ6rsrrr)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /INPDES/
<br />DISCHARGE MONITORING REPORT (DMR1
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM J :' I t TO Jci y r ,.i.3
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructiorm before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br /> MEASUREMENT
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<br /> SAMPLE
<br /> MEASUREMENT
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<br />71
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<br />:41EQUIXR?MEW -
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cendy under pens 1y o 1+? that this document and all attachments were
<br />erAW In accordance with a s
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<br />ared under m
<br />direction or su TELEPHONE DATE
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<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 Informatioo, the information
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<br />" eo submitted b, to the best of my knowledge and belief, true, accurate, and complete.
<br />SIGNATURE OF PRINCIPAL EXECUTIVE ?Q a U? U
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<br />` 1 am aware that there are significant penalties for submitting tabs Information,
<br />TYPED OR PRINTED
<br />Including the posslbnlty of fine and Imprisonment for knowing vlolatiorm
<br />OFFICER OR AUTHORIZED AGENT
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION,, UP ANT VIVLA I lVfMb I marerence sn irricnmenra narei
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<br />3
<br />PAGE OF
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. :.This 7s-a. 4-part ' form.
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