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PERNlTTEE NAMFfADDRESS (Indude NATIONAL POLLIftANT DISCHARGE ELSIBMTION SYSTEM (NP1Ms1 <br />FAcW Na7e/Cocall0nifdAererll) DISCHARGE MONITORING REPORT (DMR) <br />Nl4l6E (2 i5) (f7-19) Form Approved. <br />coo12Minor OMB No, 2040.0004 <br />Approval explm 10.1144 <br />FAGUJTY F - Final <br />LOCATNAre" MONITORING PERIOD <br />ATTENTION 'f S YEAR I MO I DAY I YEAR 1 MO 1 DAY NO DISCHARGE • . <br />FROM TO <br />( t (ZZ -73) (24-21 <br />(25 27) f2S-29) <br />f3O 11) NOTE: RsW kw&ucdom b.rore Compl0kV Mb farm. <br />PARAIIiEFER <br />(3 � <br />(3 Card Onty) QUANi1TY OR LOADING (4 Card OnW <br />QUALITY OR CONCENTRATION NO. <br />FREQUENCY <br />OF SAMPLE <br />(45.53) l54 Qt1 (-M-I.iJ' <br />(46-53) <br />(5"1) EX <br />ANALYan TYPE <br />AVERAGE 1lAXIYWI UNITS Now" <br />AVERAGE <br />MAXIMUM UNITS <br />(04.0) (00'70) <br />SAMPLE <br />1st#tt #:#tit RR*k## ##sttt <br />MEASUREMENT <br />t#s##t <br />PERMIT <br />REWREMEfiT <br />30 -DAY AVG <br />SAMPLE <br />ME4SUREMENT"mT <br />REQUIREMENTiiR#t# till## 1111#t t#!i#i <br />30-0DAY <br />SAMPLE <br />##st#t suttt a###t# <br />MFJ wREMENT <br />iPERlApT <br />REQWREMENT <br />3saAY AVG <br />i#tett #iii## <br />SAMPLE <br />MEASURMNT <br />FST #e#si# #:ityi #*eett ##R#tR <br />ANT <br />30 -DAY AVG <br />gs <br />iii#t# <br />SAMPLE <br />MEASUREMENT <br />stt#ii <br />stisit #tstti ts**## <br />Rka T tiiiti *t##** <br />30-OAYAVG <br />#tilit #tint #i#*t# <br />AMPLE <br />i#kk## #tttit #til#k <br />MEASUREMENT <br />IPEROUT ###yyy t##*#s R*#1st <br />RE;kLqREMENT**404 <br />3"AY AVG <br />iii*#t <br />#t#*ti #lit#t tt#iii <br />SAMPLE <br />MEASUREMENT <br />PERMIT <br />##i#*# <br />30 -DAY <br />a#i## <br />NT ##lilt #R#ti! <br />NAfAEIiTILE PRDlCLPAL EXECU1WE OFFICER <br />1 CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND <br />TELEPHONE <br />DATE <br />�/► ii <br />0. �� <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON YK <br />INQ'ARY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR 011TAINWCI <br />i�r�O 11� <br />THE INFORMATION, i BELIEVE THE SUBMITTED INFORMATION IS TRUE. ACCO. <br />RATE MND COMPLETE <br />0 rely � i VI\ <br />I AM AWARE THAT THERE ARE SKNFMANT PENALTIES <br />FOR SUBMrIT O <br />FALSE INFORMATION. INCLI1gNO THE POWINUIY OF FINE <br />AND IMPRISONMENT. SEE M 001 U.&C 91AND 33 U.SA. / 1311L <br />11 <br />V 6Y �� <br />TYPED OR PRIllcm <br />(ams orbs. Own sMA" may rgrrds ann up to iro ow and or maahaan $qNA <br />AL <br />hpho www dbanuan a mmwa and 5 pain) <br />OFFICER OR AUTHORIZED AOSNT CODE NlLYBER <br />YEAR 100 JD AY <br />CUM LArum <br />BSA FORST 332&1(REV. a M Pmyj rra aragons aiyr ba mad; <br />Tap [R <br />EALACES 18'A fOFORMYYIMICH MAY NDT E$ IM" <br />000051950315-1633 <br />PACE 2 OF 2 <br />