PERMITTEE NAME/ADDRESS Qnc(ude Faei(iry NemdGocndon JDiJjerenq
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<br />NATIONAL POLLIfTANT DISCHARGE ELIMINATION SVSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMfl)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
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<br />NOTE: Read Instructions before c mpleting this Sorm.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br /> REQUIREMENT .5 ~~~
<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER IOerGN antler penalty or law tom tnK document and an anacnmerns were
<br />d TELEPHONE DATE
<br />5~ ~~ `,~Lj yJs ~e~'~' preparetl under my tlirection or supgrvision in accordance wdh a system designe
<br />to azsure Vial qualified personnel properly gather and evaluate the inlonnation ~
<br /> cubmtlad. Based on my Inquiry of me person or persons who manage the system,
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<br />subminetl rs, to the best of my knowletlge end belief, Ime. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ~(~ 6~s'43 ~ ~ O Z Z[-
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<br />TYPED OR PRINTED 1 am aware that there ere significant penalties for submitting false inbrmation,
<br />includin the ossibili of fine antl im risanment for knowin violations. OFFICER OR AUTHORIZED AGENT
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<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS {Reverence al! attachmen(s here)
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