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PERMITTEE NAME/ADDRESS pnclude Facility Name/Locarion fDi$esenr)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ~) TO ' U.i 1
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />n04D J3 TO «F.ST RlIZ7.AEtJ GOLCH
<br />=K~r NJ JICChA9GE ~~J #~#
<br />NOTE: Read Instructions before completing this form.
<br />~GFAT
<br /> QUANTITY OR LOADING OUANTITY OR CONCENTRATION NO. PREOUENC SAMPLE
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