PERMITTEE NAME/ADDRESS (Include Fanllry Nmnr/LoCaNnn ifOtperart)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form AppfOVed.
<br />DISCHARGE MONITORING REPORT (DMAJ OMB No. 2040-0004
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<br />PERMIT NUMBER - IscHARCE NuMeER F - ` ; '. 4 i. `:• n v 6 N
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<br />YEAR MO DAY YEAR MO 'DAY _
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION •~: NO. FREOUENC SAMPLE
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