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<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (N-UESJ Form Approved.
<br />DISCHARGE MONITORING AEPOAT (OMR} OMR No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER ~ _ ~; h ; .,
<br />MONITORING PERIOD '' ~'( ~' -' ~ ~(~'`"' ~~~) ~- q ~" -
<br />YEAR MO DAY YEAR MO DAY
<br />FROM '.: TO I, -. ~- ~ ; • ;'-. ..:. 7 ~:~<;:
<br />NOTE: Read Instructlans berore O pleNng this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENT)iATION NO. FREOUENC SAMPLE
<br /> EJC of TYPE
<br />PARAMETEA AVERAGE MAXIMUM UNRS MINIMUM AVERAGE MAXIMUM UNITS ~~
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<br /> MEASUREMENT
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER ICargry under pena;ry aNawthm this document and eY enachmenLx were TELEPHONE DATE
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<br />~ ~ ! S 7.~-L~ ~.- PreParod antler my duecuon or aupan~nion in ettwdance vnN a systom desgned
<br />to asswe Nat QuaYfied personnel pmpe,ty Bather and ereluate the inbrmation
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<br /> ¢ubMned. Based on my Vrpvry d tna person a persons vmo manage the system,
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<br />ortMSa persam di,ecdy responsible br ga,nerinB n,e iMOrmaLOn ' ~
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<br />submmed a , to the best d my Mrwwledge and lx11e4 tNe, acGUrele, and complete.
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<br />SIGNATURE OF PRINCIPAL EXECUTIVE y
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<br />TYPED OR PRINTED 1 am aware Inert there nre signdwant peneides for submmlrg false Inormat
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<br />incNGn the ssihli d rme and an isonm¢nt ror knavnn riaatbre. OFFICER OR AUTAORlZED AGENT NUMBER YEAR MO DAY
<br />OMMENTS AND E%PLANATION OF ANY VIOLATIONS (Reference all attachments here)
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