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PERMITTEE NAME/ADDRESS rlnrludr Farilin• \'Amr/(oration iJpiJJerrntr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Fcrm Approved. <br />OMB No 2040•CX3U4 <br />N(1TF• Rnari h, ofr~rn+i., r,r time,,.., ~., .,i., ~ti~.. f,,.... <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX ANALYSIS TYPE <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ; <br /> <br />MEASUREMENT ~ <br />~ <br />- <br /> , <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />!j <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r <br /> MEASUREMENT ~ <br />.; ~- <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br />A ~ cJ I~ -'~" <br /> ME <br />SUREMENT ~ _ 1ti <br /> <br /> PERMIT • - <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />~ ~ ~ ~~ '-' <br />~ • ~ ~ ~. <br />'~ <br /> PERMIT . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I rrrtif~ under prnulN .d law that Ihi+diwonn•nl umi all .rttarhurrm. „err TELEPHONE <br /> <br />prep+rcd umkr m~ dirrchrrn err +uln~n i.irm in un~wrdunar wish a +r +trm dr+iltn.vl <br />' DATE <br /> lu u~surr Ihat yualifiad prrvmnrl prnprrl~ euthcr and r+uhnQ ibr infurmulinn <br />i <br /> .ubmiucd. Ru+rd un m~ inyuin ut the (xrwrn ur pa nam who manegc the ydem, ~ . <br /> ur thwv~ penom dirt<Ih rc+pm+ibk fur ¢athering the inturm:aiwn. IM• infnrntaliun <br /> <br />+uhmiurd is, m Ihr br+t of m+ AnowlydQr •uul trrlicr, tnw~, ncruratr, and nrmplrtr. <br />I um aware thnl Ih <br />l <br />ifw <br />i ~ <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />I <br />- <br />..` <br />~ / <br /> <br />I ~ <br />TYPED OR PRINTED erc are c <br />vnl lr,vcJi <br />r. for +ubmilliny; tube inrurmutiun. <br />Rn <br />imiuding the l>,r+eibiliq of fine wtd impn,umnrm tar knwwine +iulatiuns. O ICER OR AUTHORIZED AGENT AREA NUMBER <br />C DE YEAR MO DAY <br />f`f1~A f1AFNTC A~lfl FYPI ANATIf1N AF ANV Vlfll ATtrIIJC /v.. s .............tt _ __~~__._ ~ <br />~E l"T~..F~ r';:31~ i ' ;,.•,t_ - e,., I_ I r•1 ! (5 id>'I I Vk~ <br />r~ur-n c.t- _... ~1~ t- ! T7 i Y' Ti5'=; !nr-lr l <br />-I-hi. i~ ~t -l I~iu-t fr~rn~. PAGE OF <br />