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PERMITTEE NAMEIADDRESS rlndude Farilitr ,\'amdLxatiun if lliffrnnn <br />NAME <br />ADDRESS ` <br />~:: ~; __ , <br />~. J <br />FACILITY <br />LOCATION ~=~ <br />,T <br />GO Ei 1 4~4 <br />!>r i'tAPdAtzER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERI00 <br />YEAR MO DAY YEAR M DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040.OOp4 <br />1 I NE GR iJG TC <br />i/. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX rsls TYPE <br /> ANAI_ <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> __- <br /> PERMIT .. ,. -c <br /> REQUIREMENT ~ •.~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , .- .... r. - k• _ <br />~ ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .~ .. ... , <br /> REQUIREMENT ~ i;. <br /> SAMPLE <br />_. .~_ MEASUREMENT <br />'' PERMIT .. ~• . <br />~ ' _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ - _ _.. _ <br />" <br /> REQUIREMENT ~ - ; .;; ~ • . <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ~ ,..: <br />~~~:•~ <br />. <br /> AEQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _.., a ._., .. .- . .. _, ... <br /> REQUIREMENT ~ ~ ` L i ~ . • ' <br />NAMElftTLE PRINCIPAL EXECUTIVE OFFICER f ceniq mrtlrr prmlt> ..r law chat mi. document and all attachmrnb werr TELEPHONE DATE <br /> prrpared under m~ dirretinn ur wprrsisinn in aax nrdam~e with a y+lem dr+igard -..-._ _ _ <br /> to axurr that yualified perwnnrl prnperh gather and es aluate the informatow <br />~ <br />- --- ~ - - "' whmiurd. Nn+ed on my inquiry wf thr Ix rwu ur person+ w hn nwn:ytr thr s. siren. ,- ~ ;~ <br />I <br /> ur lhu+a• penun+ din•ctly rnpcrosible for rathrring the Inlnrmatirm. thr infornwfi~m , <br />~ d b <br />d <br />kt <br />hd <br />li <br />f <br />t ' <br />' <br />l ~ <br /> , true. accura <br />e. an <br />nunp <br />n <br />wbmitlsd h, m the best n! m+ kmrw <br />ge an <br />e <br />e SIGNATURE OF PRINCIPAL EXECUTIVE . <br />' <br /> 1 am aware that them urr +ignifkanl penaltle. !ur whmiuing raise information. AREA <br /> riwmmrm fur t.a~~wing ciulatinn+ <br />ibllin u! f <br />and im <br />th <br />~n <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT D NUMBER YEAR MO DAY <br />TYPED OR PRINTED p <br />- <br />ng <br />r p <br />+ <br />ine <br />nc <br />u <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />IMF <br />- _ p:. ~ _. <br />This is a ~-part form. PAGE OF <br />