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PERMITTEE NAME(ADDRESS (Include Facility NamefLoronan ifDif(erenq
<br />NAME fiLJ:; `'J111i!'.;I?: ., :;EK'Y, LtiC.
<br />ADDRESSU ~: j L g A D.7 ' 1 N ;•,
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<br />FACILITY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOESJ
<br />DISCHARGE MONITORING REPORT (DMA)
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<br />PERMIT NUMBER DISCHAFjGENUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY ~ Y R MO DAY
<br />FROM I! - 3
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<br />Form Approved. ~
<br />OMB No. 2040-0004 ~
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<br />- FINAL fO~
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<br />., NOTE: Read InstrpC _ ns6eto~e co 1pleting this form. ~
<br /> QUANTITY OR LOADING OUANTITY OR CO C tGN ~~ NO. FREOUENC SAMPLE
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<br />PARAMETER AVERAGE MAXIMUM UNIT$~' MINIMUM AVERAGE' MAXIMUM UNITS ANALYSIS
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<br />F, LU.:NT ::OiS VALU AEOUIPEMENT ~: NO=U ~~ ~;, _«.
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICedlry under penalty of law that this dOCUment andall attachments were TELEPHONE DATE
<br /> prepared under my diretllon or supeNlsioli in accortlence wnh a system designe0
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<br /> Ism aware that Nere ere signficant penahiea for submitting lalse inbrmaGOn, OFFICER OA AUTHORRED AGENT NUMBER YEAR MO DAY
<br />TYPEDO PflINSED includin the ssibili of fine and im risonment for knowin wolations.
<br />GOMMtN I S ANU tXYLArvA I I V rv V r AN T V I V W I I V NJ lttelerence au aaacnnlems none/
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<br />orm `3 f?rewUus editions may be used. 0047'1/000~/17IiS A4•PART FORM PAGE 1 OF
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