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PERMITTEE NAME/ADDRESS ilnrladr I•ncilitti ~nmr:'l.oouirm i/ ItiJj~rrnri <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No- 2040.0004 <br />:t•Ji~~li Tti;i3 T <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , -, r: ~_ <br /> REQUIREMENT i ~ - - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 ('crtiq al(drr prnau~ or tae thm Ihi. dlrumrtit and all attachment. »ere <br />d TELEPHONE DATE <br /> prepared under m~ dinrtion nr .open ision in accordance »hh u gstem deaiRne <br /> In a«UfC thol ItUatifle(1 pr R(MUCI pr~lpe rl( Italher a1Uf fa'at UUle thr mft~firlUUtM <br /> suhmht(d. Flard nn mr imtuin of the prruM or perwns » hu manat:r thr ryetem, <br /> nr thnsr q•n~M. dirrctl~ raponsiblc for quUuring the infnrmatrM, thr information <br /> whmitlad i.. bl the txcst of m~ kno»IrdKr and txdkf, trw•. accurate, rod clMtpkte. <br />b <br />itti <br />f <br />til <br />( <br />l <br />lti <br />f <br />f <br />l <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- <br />- ~ <br />TYPED OR PRINTED n <br />ormu <br />M. <br />I am a»arc tfial Ihrrr arc si~nt <br />a~n <br />pcna <br />e( <br />or su <br />m <br />ng <br />a <br />x <br />inchldin thr ibilin of tint and im ro nmcnt for kno»tn i dations. <br />t: ~„~~. P ~~ e ( ( OFFICER OR AUTHORIZED AGENT AREE NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Forth 3320.1 (Rev. 3i96) Previous editions may be used. Tlilti IS tl 4-part fOf'Rl. <br />