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PERMITTEE NAMElADDRESS rlncludr FariGrr .~ame.'f.xadan if Uiffirem <br />NAME <br />ADDRESS <br />,i <br />FACILITY F~;.; <br />LOCATION ~_ ~ <br />'_k <br />C O i; <br />~ rnAraA~~fi <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTE61 ((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 />!~ ' ~ <br />NOTE: Read Instructions before completing this form. <br /> <br />NO FAEOUENCY <br />SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . OF <br /> EX YSIS TYPE <br /> ANAL <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - ~' <br />~ , <br />~ <br />/ <br /> MEASUREMENT - ' <br /> PERMIT . - . - ~.. , . ~ , _ <br /> REQUIREMENT ~ :,~~ ~' ~ I'tUP1 <br /> <br />SAMPLE <br />,. •- <br />-- <br />_ <br /> MEASUREMENT <br /> ~ - <br /> REQUIREMENT _.. _ <br /> SAMPLE ..-~- <br /> MEASUREMENT <br /> PERMIT ,. s; <br />• <br /> REQUIREMENT '~-. i~ <br /> SAMPLE ~ ~ ' <br />,. (: oa MEASUREMENT ~ <br /> <br />.~ j PERMIT - ,. - i. r . , . , - . <br /><;`.' <br />• • ;iL',~; <br />• REQUIREMENT .. . <br />. <br /> <br />- <br />~ SAMPLE <br />''~ Q ? <br />• ~ MEASUREMENT <br /> x , ~ ' <br /> PERMIT - -. >- .. s- - . :: .. ,... __ <br />_ <br />=::OP''• • `~ ~% <br /> REQUIREMENT <br /> SAMPLE _~ I <br />` <br /> MEASUREMENT <br /> PERMIT ~ .. - ~ • <br />. , ..' ~: <br />_ <br />- REQUIREMENT <br /> SAMPLE 1) ~,_ _ <br /> MEASUREMENT <br /> <br /> PERMIT - <br />;•~~.:. <br /> REQUIREMENT • <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiq ender Ix•nau. allow lhal Ihis d.xument mul all auachments were _ _ <br />~ TELEPHONE DATE <br /> prepaml under m. directing or supers i.iun in accurdancc with u s3 stem designed - ---~---~ <br />~ <br /> to ncsure that qualified persunm•1 properly guthrr and rsaluate the informutinn ; ~ ~ ~ <br />~ <br />_ -- -----` _ suhmiurd. !lased ug mi igquirs of the person or prrvnu whu manage ,hr system. / <br /> rrums direvU~ rrslwmaihlr for gathrring the information, the inlurmation <br />or throe ~ <br />- - <br />- p <br />k _ <br />_ <br />~ : ~1 ~ <br />~ ~ ~ ~ <br />r <br />' <br />i :. ~,~ <br />' te. <br />whmitted 6. to the bell ut m~ -nowledge and belief, true, accura[r. and s~xnp SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />~ ~ ' i <br />~ <br /> tam aware tlut them arc signifa~ant p<nalUrs fur whmitting fal.e informatiug. AREA <br /> si~dntimis <br />d i <br />i <br />m f <br />kn <br />wi <br />i <br />d f OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED O PRINTED . <br />umme <br />or <br />o <br />gg <br />hkhaiing the po5sibil <br />ine w, <br />mpr <br />q . <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference atl attachments here) <br />L i i'I I T ~wP±_ f I` U Ft]R_ C1YR, ~ 4HF2 ?REC T. P EVENT - ~t.E I A. 2, <br />-T'~ `.. ; . -• t'. ,. ,, PACE OF <br />cps - _ ~P., -. _ _ <br />