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PERMITTEE NAME/ADDRESS (/nclyde Fadliry Nm,w/focadon tfOifferert) <br />NAME __ <br />ADDRESS - : ,; ~~ ~. ~ ,.: ~, <br />. .. t <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPOES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR) OMB No. 2040-0004 <br />~f',,; ~. <br />.~ ,w <br />PERMIT NUMBER DISCHARGE NUM6ER ~ ~, I ~ •~ r . • ;~' <br />MONITORING PERIOD ~ - , ... ~ . _ r. ` -: I '. '= F'J' :' `' ~ <br />YEAR MO DAY YEAR MO DAY <br />FROM '. ~ .1 TO .1 1 _I r. ~. r: ~: , ~ J :,':., F ~~.:: ~ ~ __ ~ °' ~''' <br />NOTE: ReadLlnstrudlons before completing this form. <br /> QUANTITY OR LOADING OUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br /> EX of TYPE <br />PARAMETER <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS /~Na-YSIs <br /> <br />_ tl' it <br />'~ `~ SAMPLE <br />.. .. ..... ,.:.. <br />... <br /> <br />~ /~ s ~_: :i '::. :. { ~ ') / <br />L 3 MEASUREMENT O / <br />U GJQ'STiP <br />. ~ a ~ V '•,YO 1' y~ <br />n.. '. ~ <br />V1V ~r .y NfX ~±w 4"Y '~PTIIT~ ~. ~Y 9' ( <br />~ <br />~~`Yp'k ~~ - <br />) ~ v HE~LUI~i~IN~NT' "_ !I ~I V A L'J ° c ~ <br />_ " <br />~. ~" ~' .: ~1 ~~ ~., r. '.:. SAMPLE . .. <br />.,_.. ,.; ....~ :. .. ~- ... ( .~'r) <br /> <br />- <br />~ <br />MEASUREMENT <br />7 /pfl~ <br />O / <br />90 <br />6,~~d <br />. ., _ <br />~ U ~ 7 * ##+DM,=-.: ~ _ ~ ~ >x>R~#~^t - ".~09r, ~e{e ' ~ ~ - <br /> -a ~ L . <br /> SAMPLE <br /> MEASUREMENT <br /> e i <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> I <br />Y~4 <br />j <br />R <br /> E <br />~1T <br />Ei~QUIR <br />~ <br />4 x ~ =Ai(q - <br /> SAMPLE <br /> MEASUREMENT <br /> y1~ k <br />ar x,+z . .~. ~ m`.. ,.~ ~'t <br /> I r . <br />SAMPLE <br />SAMPLE <br /> +? wI'~L M '~'e~~'~ ?iy_'l" i. <br />~*+4 r j X~}'tix 'y5 r,*~' _ SI "e~" _ r~ <br />It " ~ ..~: .. <br /> ilGV 4r ~ l ,'Y ,. x <br />x i,,, ' N 17.. _ <br />` e <br />NAMElTITLE PRINCIPAL IXECUTIVE OFFICER ICeraN untler penalty of law that Nrs tlowment antl all attachmarss ware <br />rvisio <br />ccordanc <br />with a s <br />ste <br />d <br />di <br />tio <br />i <br />d <br />i <br />d <br />d TELEPHONE DATE <br /> y <br />prepare <br />un <br />er my <br />rec <br />n or supe <br />n <br />n a <br />e <br />m <br />es <br />gne <br /> b assure U,et qualAleO personnel propedy geNar end evaluate Ne Inlonretlon <br />ReeatlonmylnquiryolthaPereonorpereonswhomarlagotheeystem <br />submitted <br />~ <br />/ ~ ~ <br />- <br />CL <br />W'. ~Jordc~tt Peters . <br />, <br />or throe persons directly reaponsibte br paNedng the IrMSnr,etlon, the 7nforrnatlan __ <br />rr. <br />- n~p_B_.r,-4101 ^! 'J7 'S <br />~' a '.71t I G 2116 ra 1. -,lane e Y <br />Pr i aubmllted le , to the best of my knovrledge and ballet, true, accurate, end complete. <br />i <br />enela <br />for <br />bmitti <br />l <br />ke lnrom <br />ti <br />n <br />th <br />h <br />el <br />rt <br />I <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED gn <br />p <br />, <br />sm aware <br />ere ere s <br />car <br />es <br />su <br />ng <br />a <br />a <br />o <br />at t <br />Inclutllna the rnssibilirv of fine end lmpdsonrnent for knowirsl violations. OFFICER OR AUTHORIZED AGENT rnno NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reterance all attachments here) <br />.. i <br />A grin 3321 (REV 3% 9) Previous ~editioris may be used. ~~ ~ ~ ~ • ' - ~ -, TMS IS A 4-PART FORM ' PAGE ~' ~ OF ' <br />4 <br />