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PERMITTEE NAME/ADDRESS Qnclude Faclllry NamdLorutbn IjDlffumQ
<br />NAME _
<br />ADDRESS i -, ~ ; i .~.:_ l
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLIfrAM DISCHARGE ELMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMH)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM "+ TO ~i ~'~~ .+7
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NOTE: Read Instructions~betore completing this form.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREDUENC SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I teddy under penalty of law Chet this document end all attachments ware
<br />d TELEPHONE DATE
<br /> preparetl antler my direction or eupervislon In eccortlarrce wah a system
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<br />President/~@narai F~8[18"@L ,
<br />eubmlhetl la,bNe beet of my knowledge end ballet, bue, accurate, entl complete. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED I em aware Nar there are signmrare penaltlea br submitling false Inlormetion,
<br />inclutlin the ossibil of M1ne and lm risonmenl br knowin vbletians. OFFICER OR AUTHORRED AGENT
<br />NUMBER
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<br />COMMENTS AND EXPLANAI IUN OF ANY YlOLAI lulus (Hererence a!! attacnments nere)
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