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I <br />Form Approved. <br />PERMITTEE NAME/ADDRESS ilncludt• £uility.\'arnr/lauatinn if!)i,(Jrrrnfl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB NO. 2040.0004. <br />NAME ~ DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER " <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Read Instructions befor completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX NALYSIS TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - <br /> • <br />•~ <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ' <br /> PERMIT . <br /> REQUIREMENT ' ~~ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMElf"ITLE PRINCIPAL EXECUTIVE OFFICER 1 r.•rtir, lmdrr prnau> of law that mi, d1K11mrm um1 qu attuahmrnt. aarrr TELEPHONE DATE <br /> prrp:u~avl under m~ dirarhon or wpen i.iun in acrunlunce Nith u wstrm de,iKned <br /> I~~ A"Il ra' Mgt ynghlled 1Knnnllel proprrl~ Rglhrr and to ainglr Ihr Inf1Hl11all~m <br /> ,uhnuurd. R:urd nn m~ inyuin 1d thr {1rn.w or pa•rvm, who manukr the ,a,tcm. <br />nr thina• pa•nom dinti9l~ rr.p~gl,ihla• fur ylthering the ininrmntilm, the infulmutiun ~~ <br /> wbmittad 6. In thr lx~,f of m~ f.nuulrAs;r w1d Ixhef. 1n1e. ucrurga•, nuA rnmpletr. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />- ~ ~ <br /> I am aegre that thrn• un•,it;nifiagnt Ix•nultir, fur ,uhmiuin~ ful•r infurmutiun. AR <br /> rnnnrmmt Grr knuwinK ainhdiun, <br />ibilih 1d fi <br />nd im <br />i <br />di <br />Ih <br />x <br />r <br />i OFFICER OR AUTHORIZED AGENT pE NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />p <br />m <br />u <br />n~ <br />r f <br />xa <br />n <br />a <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />- i ~ 3?20-1 (Res ~ .. -,~~< <=~~a~~ . <br />rc~rlll. PAGE OF <br />