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PERMITTEE NAME/ADDRESS /lnrladr h'arilue Aontr!laralinn iJDifJerrnt) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS ~' ~~ ' <br />D Lt y .: PERMIT NUMBER DISCHARGE NUMBER <br />I`P' MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ~}~ FROM TO <br />Form Approvetl. <br />OMB No. 2040-0004 <br />NE rRiv <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> <br />EX <br />ANALYSIS TYPE <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> - <br /> PERMIT _ <br />~ • ~ f`'IAX i i~~~ '•' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> . <br /> PERMIT ,. ) , ., -, ~ r~ <br />.:,.) ; ., <br />~~,!-,;~. •.:,-- <br />.. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - <br /> PERMIT ~ ; ~ . _ .,!~ <br /> REQUIREMENT ai< l r; .~; ,' ::~.: i;',~; r~i`•.'C~ <br /> SAMPLE <br /> MEASUREMENT <br /> _ . • ~, <br /> PERMIT .; -:. ... ,,.rz ~ ~,~ A _ <br />- REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - t _ , <br /> PERMIT . - .- . . ,. - - <br />:3~:''":- - - <br />C~:` : ~ ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PEAMIT <br />~ <br />_ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - <br />. ,. . ,. - _ _. <br />` PERMR <br />REQUIREMENT _ f. <br />~ -' ' ~' ~' ~ ' - . <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l .eriiry ender prnaln of law that thh d~R•umrnt and all attachm<nn were TELEPHONE DATE <br /> prepared undrr m) direction or wprrsision in ucaKd:mn• with a .yilem desittard <br /> la wwrr that yiwlifird penonnd pruprrly lnlhrr and e. utualc the infarmutioa - - - ~- --'- , <br /> wbmittad. Nxsed nn me inyuin ~~ the person or persons who manuie the .} ~trm, I ~,.~ <br />_~ <br />'-- " -"'~ - ~msihir far gathrring the information. the information <br />rson. directl <br />re. <br />n <br />thos ~ ~ '. }g . <br /> y <br />p <br />r <br />e pe ., <br />~ ~ ~ I <br />i - <br />_, <br />_ ~ , wbmiltrd is, In thr best of my knawlydgr anA brllef. true, accurate, turd compMe. SIGNATURE OF PRINCIPAL EXECUTIVE <br />t ~ <br />- I am aw arc that thrre are sixaificam prnalttes for submitting falx information. <br />AUTHORIZED AGENT <br />FI <br />E AREA <br />MBER <br />YEAR <br />MO <br />Y <br />TYPED OR INTED irmiueink the pos`ildlih of fine and imprunnmrnt far kmwinR sl"t+f1~t OF <br />C <br />R OR NU DA <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) r~ I T M 7 T ;wot- r r,~ Ft~P ? OYR /2.~-HR FAR)=C IP EVENT - SEE I A 2. <br />Tlr. ? ,~ ~ PAGE OF <br />., , ,... <br />I ~ -. _ -. <br />