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PERMITTEE NAME/ADDRESS tlndudr F'aciliry .Name/Lxmion iJlhpoentl <br />NAME <br />ADDRESS - ' <br />..1 ,: !- <br />FACILITY : i(J~ ]' ~:~[•i ~ _ , , _. <br />LOCATION L~-~ : ~~ ~. <br />•..~, .+ ,~nTY~ M1n TI.IL MAl.IAl~L: <br />Forrn ApproveLl. <br />OMB No. 20440004 <br />NOTE: Read Instructions before completing this form. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMRJ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YE_A MO DAY YEAR MO DAY <br />FROM TO <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY SAMPLE <br />pp <br />ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> REMENT <br /> MEASU - <br />: . <br />t .~ _ _ O' - .. . <br /> PERMIT <br />REQUIREMENT <br /># Y:' # # 3: 'Jrr <br />s_ ' i ! t <br />.. :: it"t, fi~ : <br />: t: <br />.. <br />R :. <br />, <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> ENT <br /> MEASUREM <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MENT <br /> MEASURE <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> SUREMENT <br /> MEA <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> REMENT <br /> MEASU <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I errtify under penalty o(lyx mot mis doeumrnt and all atwehmrnl. xrre - TELEPHONE <br />prepared under my dirrcliou or snprnisirm In accordance with o +y stem designed r _. -~ <br />to n++ure tlml yunlifird prrv.mnel properly ~thrr and r. aluutc the infurmution <br />whmitted. flused on my inyuir. o(Ihr person nr prrvms xho marmgr the ssstvm, ~ '(\ <br />- DATE <br />_ <br />. <br />"~- ~ -~ ~ •~ --- nr thou penorn directly resgrn+ihlc (nr grdherin{t the infurntatWn. the in(ormafion ~ <br />to for txA u(my Ynuxkdgr and belief. Irur, orcurute, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE "-~ ~ ~~ <br />+~ suhmitted ~ , <br />-~ •r ~ "' <br />' ~ '~ . <br />I am axare that there ure significant pcnuhies fur suhmitting falac informatMn, OFFICEfl OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br />TYPED OR PRINTED including the prnsihility of riot and imprisnnnrrnt for knax inK si,datirms. <br />~~ ~t OD <br />COMMENTS AND EXPLANATION OF ANY VIULA I Iulvs I-•rererence nn duncrr,,,c„ra <br />OG3Y_: This i, a 4-parr f"t~nn. <br />nc, c~ <br />