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PERMITTEE NAME/ADDRE$$ (/nclude Faciliry Namdlocanon ifDij/erenQ NATIONAL POLLIfTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form ApprOVed. <br />NAME ..., DISCHARGE MONITORING REPORT (DMR) <br />r, ~ ...- „ • ~ - ~ , r _ J OMB No. 20460004 <br />ADDRESS,_• - ~ -, I ~~ , ~ <br />(~;: ':i <br />. ~; ~; ~ I ~ J . ~, PERMIT NUMBER DISCHARGE NUMBEq _ .. ~ <br />FACILITY - - `" ~" MONITORING PERIOD : -•,y S~ ,~.__ ._. ,_ . <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO ~.I - '. ~i. .-.:: is '~~ ~•- i .,. ~ I ~/( ... . <br />~ ~ ~ - NOTE: Read Instructions before completing this form. <br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. EREOUENC SAMPLE <br />PARAMETER ~ EX oP TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~~19 <br />.:l L ,- I - SAMPLE .. l ..1? ... ~ .. <br />,.. <br />~ MEASUREMEN7 <br />'-%'~' ~ I PERMIT =~~'. `. - -~ y ~~~_., re:pt~i::[ - :..-.a 1=:.~; ~. r>.. :. 'r' SUR <br />r ~ ~~ ~ _, ;: REQUIREMENT - - _ F: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />~ <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I Certify under penalry of law that Nis document and all atlarJrments ware TELEPHONE DATE <br />/ y- y. <br />~l( /'i S r ~~ ~ <br />~ ~ <br />S ~ preDeretl untler my dueaon or supaMSlon in accortlenca wiN a system tleslgnetl <br />roperly <br />ather end svaluata Ne Inbrmalion <br />to assure that qual,fed <br />ersonnel <br />~L <br />/ <br />L <br />:'/ p <br />g <br />p <br />eubmittetl. eased on my Inquiry o/the person ar persons who menage the system, ~ __- <br />ri <br />r <br />~/ <br />/~,~' <br />% <br />-- . <br />~;~,r <br />` ~ <br />~ <br />fcr ~6• <br />_ <br />,: ~%(! ~---,fie / ~ or NOSe persons directly responsible for gat0anng Ne lnlormation, the inbrmetlon <br />submitted Is, to the best of my knowledge and beliel, true, accurate, entl complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~, <br />77U y <br />7~ ~3 ~ ~~ <br />C+.~ <br />~~ ~ <br />~b <br />TYPED ORPRINTED I am aware Nat mare are sign cant penalties for submitting false information' OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br /> Inclutlin Ina ssibili of l,ne and im risonmenHor knowin v,olations. <br />l:V MMCN I J ANU hXYLANA I IUN V F ANY V I V IA I TUNS (HelelenCe a/1888Cflmeli[5 ^ereJ <br />0 <br />EPA Forrri 3320.1 (REV 3/9~) prev(ous editidns may be used. T_ HIS IS A 4-PART FORM PAGE OF <br />