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PERMITTEE NAMElADDRESS ilnrlude Fmi/in .Vaxtdl,oration if DiJJarn11 <br />NAME - ,;:•I l , -- . <br />ADDRESS +-'-- I <br />:;{ •_ <br />FACILITY _ - _ <br />LOCATION ;i - " <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />E OF <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE "} <br /> MEASUREMENT <br /> PERMIT '' y~• ::" Ir'~ _ ~" is •; <br />• REQUIREMENT If\i~T PIF+X <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrrtif+ undrr yrnalt7 of lur that this document and nll ntturhmrnl+ rem <br />d <br />d <br />di <br />ti TELEPHONE DATE <br /> prapare <br />un <br />er mr <br />rec <br />on nr wprn felon in aarontnace arith u a)atrm dr+ignad _ _ ___ <br /> to x~+un• that yunlified perwnnel properk pyther and ernluute tlm infurmatirw <br />-- " ' • --- ~ wbmitlyd. Nx+ed on m~ inyuin of the pawn nr prrwrts rho manngr the ystrm, <br /> ur tho.r pcrvtns dirrcd) re+punsil>le for ytxthering the Infurmntiun. the in(ormution - <br /> <br />eubntitted lc, d. thr Iret of my knurledge and hrlirf. true, accurate. and compk9e_ <br />~ ~ ~ ~ 1 <br /> <br />I nm uxnre that them are +ignificunt prnaltlc. fur wbmitting false informotioa SIGNATURE OF PRINCIPAL EXECUTIVE <br />l " t <br />TYPED O PRINTED including the p~neihility of fine and impriwnment (or knnring aiululiunt OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MQ DAY <br />COMMEN 15 AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />-C <br />EPA Form 332G-1 (Rev. 3/99) Previous editions may be used. <br />This i a •~-part tone. PAGE OF <br />