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PERMITTEE NAME/ADDRESS ibxfudr F'at•ilin Namellixalion iJlhJfaml <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />,~; <br />O d l c~':35' <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 />I'17 <br />F <br />Form Approved. <br />OMB No 2040-0004 <br />,~ , <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N~, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REOUIREMENT <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 /> REOUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I rerun under Ia•naln of lua that thi+d~aamem and uu unachmrnt. wen• <br />~• TELEPHONE DATE <br /> prrpand under m. dir<<•lion nr +uprniciun in uccorduner wish u +++tem de+i~twd 'I <br />~ <br /> Ina+,urr that qualified prnnnnel prnperl> Lalhrr and e+uluaR• thr inGrtmaUiat t <br /> <br />whmitlyd. Ru+rd ..n my inyuin of the pen.at nr prnnn+ whu manure thr .~+tem. w <br />~ <br /> nr Ih~ne prr..m+ Airn'd~ rr+pm+ihk fnr gutherina the infnrmati~~n, the infurmntiun <br /> and eo <br />A h <br />li <br />t <br />r <br />u <br />t <br />l <br />[ <br />R <br />l <br />f I <br /> nuw <br />ntr, u <br />c <br />ru <br />r, <br />mp <br />r <br />a <br />whminrd i+. u. dte last ..f m+ <br />rslt;r un <br />r <br />r <br />. $IGNA RE OF PRINCIPAL EXECUTIVE f - ~ <br /> I um uu un• that thrn urr +iRnificam penultie+fur +uhmitting fal+e informatlon• <br />' AREA <br /> risonmrm for An..++in_+iolatinn+. <br />iVrilih of fine and im <br />ludin <br />th <br />i <br />^ OFFf <br />CER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED p <br />nc <br />g <br />+ <br />e M C D <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference al! attachments here) <br />- ~ .1.r~+~ ~ .:.Ppl T rY`• F-!'~R "=l ('1YR: 24I-If7 FR?"~~ ~ I~ ~~. r-PST; 7'SS. <br />EPA. F rri ,.__ F?..~, ~ >', i-r~,:i ,~ 7 .rhj, i'• ;? .1-n•tt"! (•r,r't~ PAGE OF <br />