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PERMITTEE NAME/ADDRESS (include Facility Nanle/Lncalion i/Diperen(f <br />NAME , <br />ADDRESS. .: (! ,,,., ('r us•~I <br />I I "I <br />... .'.i F.;:F <br />FACILITY ~' ' <br />LOCATION <br />~:i fa ~ .'r .'G:' l~ <br />NATIONAL POLLUTANT DISCHARGE EUMINATON SYSTEM (NPDESJ <br />DISCHARGE MONITORING REPORT (DMRJ <br />,.: r_.. <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM i.)U 111 C? 1 TO i?(i i '-` ::i 1 <br />Form Approved. <br />OMB No. 2040-0004 <br />.,.n I„~ .;.i. r. r.. . <br />NOTE: Read Instructions before completing this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. EaEDUENC SAMPLE <br /> E% OF TYPE <br />PARAMETER ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />~. ~(i..: ~'1 '[~:-. SAMPLE ,.,; :1 ,o n. ,:. .. .. ... .. ~ " <br />• i'•." ' , , ~ . MEASUREMENT l <br />~ ~~_ CP/~F <br />. ~ .. PERMIT .p +a tt~air it iF ii•k"&#i:} ~tl ~' t. 3 .IE.'-`#-0F#iF #if. t(.gi.ui (' 'I. rtl i:,, -, ,. 'i': <br />~~; ll l:-ply ~~r.. ;.I tl,~ <br />~ REQUIREMENT - Plid VALVE "~I.~'~ <br />__ <br />. ~..~ '-l r' ~I'./.~; SAMPLE I >; !~. y.ll .. ~. n•:r ~ <br />~ ~ <br />. I I ; : ..., ! I r,_ MEASUREMENT ~(Yq/. ~ G ~~ <br />,. ,, ., PERMIT i>•~r"r<h~#n #~•It#n"n-o- .e. :.' ;. ".5 ~ 'r•+~#+t~~•.u~ p..r. gj,~.sn I:. :I r:. : •:.: .., ..I... <br />'~li"~i I; PI' :i.r l_i.::.! REQUIREMENT I'1N VAl_!JL- _ ___ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT ' <br />- <br /> SAMPLE -~ --~~ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~ ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME?ITLE PRINCIPAL E%ECUTIVE OFFICER Icenity under penalty of law Net Nla document end all ettachmenb ware ~ TELEPHONE DATE <br /> prepared under my tllrlaodpt or aupelvlslon In attordance with a aystam designed <br />. <br />. <br />:. <br />I ~ ' e t: <br />1 t-1 ` <br />~• ~ 1 I I ~ to assure Net quelleed pereomel popenY gallrerand evaluate Ne Mk/r/Wlm <br />b <br />N <br />B <br />I <br />i <br />f 1 j <br />~ <br />~ ~%'~ " <br />. <br />. <br />. <br />• su <br />m <br />etl. <br />ased on my <br />nqu <br />ry o <br />Ne parecn a perone who menage Ne eyetem, ,/ <br />i <br />' . <br /> <br /> <br />' <br />' <br />i <br />I <br />' <br />' <br />or None persona Olmclly maponalWe br geNerlrlp Ne Wormellan, Na Inlormedan <br />i' ~ h ; ' <br />.~ , ' <br />~ _ <br />/ <br />'17 Q :' 7 C; 1 <br />.L <br />" ~ <br />~" <br />Pi?:1+11 •.' 1 l t , ~ <br />.1 rti: Cj~ <br />1 aubnlhed la <br />ro the beet al m <br />Mnowl <br />la betl <br />d <br />l <br />N <br />t <br />d <br />l <br /> , <br />y <br />a <br />ga Is <br />a <br />, <br />w, accura <br />e, en <br />comp <br />ete. SIGNATURE OF PRINCIPAL E%ECUTIVE c+Ti/ ~/ <br />' TYPED OR PRINTED I em aware that Nero ere elgnlllrarlt panetew br aubmlping talsa bNOrmetlon, <br />Includl Na blli of lNe and lm necnment br lurowln vloleaorla. OFFCER OR AUTHORED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />I,UIVIIYICIYIJ /iIVV C/,fy\IVXIIVIV Vr l11Yr YIVV\11\/IVJ llltlltlltl/14tl tl1/tl4Cli/Illltl//LV/Itl/tlA <br />, , .. , .. , <br />I H I .I I?h'.i,~~ll.!', hl:l I.1F! 1 I_I 1l !:~~.I. ~l. %'i i'i 1: 71.i `'.1 i(:P!:, .:.. :. ~,t:, I !_: 'I .~ .~;I21 `!.I'ri: ~''{'I''p;..,1'.. I. I. , <br />,, ~_. - .. <br />, ,,,.. <br />t .. ~. .. .. _. . <br />,1 .'.. C.!t'1 :.'d''ll ,•'~- !!II.~J, .I :il;,"v ..;I~.i•.i .( itrl' F'•L. I'I;i I': I:'l.. .. "I p.i1 ?. i.'•I.. .'n': „;i.l 'r .. I!i. I ~ I <br />. ... .. .. <br />ten'. r!L' ..6' <br />. nd~~ rotJ 'lo ~ Omainno nAllirine Inmr he uccA , , ~ . ..• ~ ., ,': ~ '•. ~ ~ ~ ~ I~ ~ OF <br />~~ ~ ~~~ ~ ~ ~~ ~ ~ • '~ ~ '~~ ~ ~ ~~ ~~~~ ~~ ~I§~ S A b-PAbT FORM PAGE <br />