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PERMITTEE NAME/ADDRESS tlndudr facifi(p .\amr/Location if AiJfarrn: <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NA710NAL VOLLUTANT DISCHARGE ELIMINATION SV57EM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-000¢ <br />NnTF Raari Inclritrfinnc hafnra rmm~iPfinn fhic fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ <br />~ <br /> MEASUREMENT - - , , <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~ <br /> MEASUREMENT ' / ~ ~ <br />, <br /> PERMR <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 ~~~'~t~r. uodrrpen:dryofla.. matmlad«vn»•mandauauachma•m~»err TELEPHONE DATE <br /> prrponrd under m~ duration ..r wprr. i.iun In xenrdut»~o with a s~strm da: iltneA <br /> la axlrr Thal yuatified prnunnol pny»•rl~ Yslthrr and c~wlualr Iha• informali.m / <br /> .uhminad. Nu.eJ ..n m~ inyuin of Ihr prrvm nr penon. »hn manage the .)slrm. ~ <br /> nr thuv I»•nuns dincth rrsgm.ihlr G.r tiatherin>z thr Information, the infnrmatimt <br /> whmiurd i., t.. the he.t of m. Ano»led¢e and M•IirL true, accurntr, n1A rumpleie. J 1 ~=_ <br /> I um a»are that thrrr an•.i¢nif»~am <br />lli <br />h <br />Kn <br />. fu <br />ittin <br />6J <br />i <br />i <br />f SIGNA RE OF PRINCIPAL EXECUTIVE ' <br />TYPED OR PRINTED a <br />a <br />r w <br />m <br />K <br />n <br />wt• <br />+e <br />ornutt <br />I <br />it»h~dine me p~...inau, ..f tint aml Imprinnment fnr Ann»In;; .iulutiun.. OF CER OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br />nr~w~w~ru„rn ww.n rvnl wwIwTlAAI nC w\IV tllnl wTtr~-~n ir~_~______ _.. _..__.____..._ CODE <br />"fhi~ r, ;~ 4-(part fclrm. PAGE of <br />