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PERMITTEE NAME/AODRESS (rnclude Facility Nmndfornrion ijDigeamQ <br />NAME <br />ADDRESS ~ .I y <br />,r !J:' -r <br />FACILITY ~ J <br />LOCATION <br />_. .t <br />_, , .. ' <br />NATIONAL POLLIlTANI DISCHARGE EUMINA7K)N SYSTEM (NPDES) Form ApprOVetl. <br />DISCHARGE MONITORING REPORT (DMR `~• OMB No. 2040-0004 <br />J <br />PERMIT NUMBER DISCHPRGE NUMBER <br />,._ <br />MONITORING PERIOD ~~ - ~ ~ ~ ~'~'~~ ~ .} ~ ~_ ; '~ - <br />YEAR MO DAY YEAR MO DAY ,~,/ -~ <br />FROM ^`- =- ~ ~ .1T0 .- -' _ - i a C ; l- ~ ', ., ~!\ 1 '... <br />/1 1 n ! n I r'' ~~ !• O 4 ~ i . '~ NOTE: Read Instructions belore completing this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER EX of TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br />- SAMPLE ~ ~ ~ r ( - ~ ) <br />- MEASUREMENT <br />G t: •~ U i i} ~ PERNNT .. ~ ~ ~ - <br />" '„I ; ~ • ; ~ : , ; REQUIREMENT ~ ~ ~ ~ _ <br />-. ~:. ~:~ r. ~ SAMPLE .,.. ( ~ ~~ <br />I ~ ., ' '• ~ MEASUREMENT <br />- ~ D ~_ 7 PERMIT .. ... ... - .. ,. <br />' ~ L ' "_' ! REQUIREMENT - - - ~ , <br />.~i:~~ .- .. •.'.- .. SAMPLE ~ ,.. .r. i --~ <br /> MEASUREMENT <br />.. '' T1'r _ '1 PERMR - ... <br />• , ~ . ~ _ ~ ~ REQUIREMENT ~ - <br />~. <br />~ . J . e ~ - ~ SAMPLE .. .. ( <br />i ) <br />( - ~ MEASUREMENT <br />~' ~ ~ a ~ i PERMIT ~ .~ ~ ~ .--„ ~, <br />. • ~ ` ~ ~ ~ - ~ L i REQUIREMENT ~ , ~ - <br />.~ <br />•Ii. .• ~ ~ SAMPLE ~ .. ... ~~~, ~. , <br />1 ) <br /> MEASUREMENT <br />~,:i 1 .. ~ - PERMIT .,. .. .. s~ .. <br />- ~ . <br />• ; <br />I <br />c ~ - ~ REQUIREMENT ~ ~ ~ ~ <br />- <br />, ~ ~ <br />:i?'v - -.: UT.' SAMPLE ' ._) ~ ~ ~ .. . <br />,~ ,' ~ ^-, MEASUREMENT <br />. <br />_ <br />" <br />I ~ <br />L <br />G ' REQUIREMENT <br />. <br />, <br />. <br />. , <br />. <br />.) ", SAMPLE .. ~• ...~ ~ ~ _ ') <br />- <br />".._ .. MEASUREMENT <br />/ <br />v PERMR - .. ~ - <br />~ - ~ r <br />r REQUIREMENT ~ ~ r <br />~ <br />_ <br />NAME/TITLE PRINCIPAL EXECUTVE OFFICER I Certey antler penalty of law that this tlocument antl all edachmems were TELEPHONE DATE <br /> <br />~• -~ j K r u C <br />- prepared antler my tluection or supervision In ecmrtlance with a system tlesignetl <br />to azsure that qualifietl personnel <br />roperly <br />ather entl evaluate the inbrtnation ~ <br /> <br />' <br />r <br />- J ~ f " I ( l g <br />p <br />aubmittetl <br />Basetl on my inquiry of the parson or persons who manage the system ~ 7 ~ / ~ <br />~ <br /> . <br />, <br />or those persons tlireNy responsible for gaNering Ne Irrtormation <br />the inbrtnstion ~ <br />~` ~ <br />~ ~ <br />~ I <br />~ s i <br />V <br />I <br />~ <br />/' <br />C <br />: <br />~~ <br />J ~ , <br />b <br />i <br />I <br />h <br />W <br />d <br />l I <br />2 <br />. <br />~r <br />4 J <br />_ <br />_ <br />I /~! m <br />lled <br />s , to t <br />e best <br />my knowle <br />ge antl belie <br />, tnJe, accurate, antl complete. <br />su SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED l em aware that there era significerrt panallles for submitting false lnlormation, OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br /> Inclutlln the ossibili of fns and im risonmeM rot knowin violations. OE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (lieterence all attacnments Here) <br />-- <br />..,- [._ --_ .- -- .-- ~ -< a /~~~~ ~, ~ '. ~ . ~. '. -~ :- _ <br />EPA Form'332O-7 (REV'3/99) Previous editions may be used: • ' ° ~ ~ ~ - 1 - ~ ~ / _ ~ THIS IS A 4•PART FORM- PAGE - O{ <br />