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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES) Form ApprOVed.
<br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER _ ..
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<br />MONITORING PERIOD ' - ~ - ~ ~ .• ~ ...ll 4~ = '- '
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX oP TYPE
<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CeMy under penalty of law ihaz Nis dowment and all attachmenLS were
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<br />i SIGNATURE OF PRINCIPAL EXECUTIVE - • U i !/
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<br />TYPED OR PRINTED or submming salsa inbrmal
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<br />I am aware mal mere are significant penalties
<br />incluein the osslbili otrne and im nsonment for knowin violations. OFFICER OR AUTHORIZED AGENT
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<br />EPA orrri 3330=1 (R 3~9~)` prev(ous editions may be used. 0 ~5 9 1 / 0 D O 71 jHl ll1 A J-PART FORM PAGE 1 OF
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