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PERMITTEE NAME/ADDRESS rMdude F"nci(ih .\omd(~afinn ifDiff`rrrnrl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM l(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 />M I PVDR <br />s' ~ F T hli-SL <br />~: I..t.-- r rt <br />Form Approved <br />OMB No. 20x0"000 <br />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION r1O• 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 />~ _ -_ <br />- <br />~~• <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />+ <br />i <br /> MEASUREMENT -: ~.. <br /> PERMIT <br /> REQUIREMENT ~ ; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT s <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~~ v <br /> PERMIT ' ' -' ' <br /> REQUIREMENT <br /> SAMPLE -. <br /> MEASUREMENT = ``` <br /> PERMIT ~ ~._ <br /> REQUIREMENT ~ ' <br /> SAMPLE <br />MEASUREMENT <br />Uj U <br />=' (~ <br />• , <br /> PERMIT ' <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 ctrtil~ wider prnullr of law mat Illi. ducurlx•rlt and all utUlrhmrnL wrn• <br />•d <br />nd <br />ti <br />di <br />" _ <br />" TELEPHONE DATE <br /> pmpan <br />u <br />er m~ <br />rec <br />on nr 91(x <br />rrisirm in accurdancr with a y.trm desiened <br /> to assure that yuali6rd fx•nunnrl proprrh Ituthrr and r.,duulr Ihr informutinn /' <br /> suhmitted. Based on nl~ inquire of Ihr prcvrn nr ps•rwm whu m+mage the ~}Nrm. <br /> or three persons dirrcU~ rrspnmihlc fur guthvring the inGrtnwtlun. Ihr in(ornwtion / t" _ <br />I `1 <br /> whmithd is. to Ihr first wf m~ An.nriedgc and la•lirf. trw•, uarurutr. cmd complrte. <br />1 urn awun• that Ihrrr are si <br />nlfica <br />l <br />x• <br />ullil• <br />b <br />i <br />i <br />f <br />f <br />ki <br />f ~ <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED ~ <br />n <br />I <br />n <br />. <br />or su <br />m <br />tt <br />nk <br />a <br />r in <br />nrmalirm• <br />includine Ihr Ixnsihilit~ .rf ^m-.red imprisunmrnt for knowiuK INdatiunw OFFIt;ER OR AUTHORIZED AGENT AREA <br /> <br />.v....uruTC nl wwl w•rln-1 nr wuv s NUMBER YEAR MO DAY <br />i~IJ MI~V G/~rLn1~I'111v1• yr MIDI YIVLMIIVI\J II7CIC/C/I[;C 411 C1friGlllnBrlfS nB(B~ <br />O1' This i~ a 4-cart form <br />