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PERMITTEE NAMEJADDRESS rlxcludr F'arilitc .1'arne/LtKatiun ijLifJerentj <br />NAME <br />ADDRESS <br />FacIUTY <br />LOCATION <br />G FJIfJ3 <br />!~^dAG~F. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004' <br />~r" <br />i <br />NOTE: Read Instructions before comoletina this form. <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 /> 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - .. <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiry tinder prnalq .,rlaN that mic drlcumrnt and an mUt hmrnt+Nrre <br />red und <br />e <br />r <br />ti <br />di <br />i TELEPHONE DATE <br /> pr <br />pa <br />m+ <br />rec <br />on or wpen <br />r <br />ri.m in wcurdunce Nith a q+Mm deciQtmd <br /> to u+cure That gtmlifirrl prnnnnel prnperk ~rtther anA rv:duale the inronnalinu <br />( <br /> ruhmilted. RN+ed mt m~ imryir~ n! the per.nn ur penom N h.. manage the y Nem. - <br /> nr Iho+e prnon+ dirra tl~ re+prnt+ihle for gathr ring the iu(nrnlaGon, the Inlnrmatirm <br /> cuhmilted h, to the IM,t nr nn AnnN ledge and 6ehrf. tole, accuratr. unA tv.mpktr. <br /> <br />I am aNara IhW tht're are til <br />lrlranl <br />M' <br />II1 <br />f <br />h <br />~ SIGNATURE OF PRINCIPAL EXECUTIVE ' <br /> <br />TYPED OR PRINTED gn <br />I <br />aa <br />C+ <br />or w <br />mill ing faly <br />infnrmaliun, <br />including the po++ibiliH of fine uud imprinonmenl for I+IIONIng +iolulinu+. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MQ <br />DAY <br />,...... ..,.. ..... .. .. .. CODE <br /> <br />(hr~ i~ .I ~1-h;nl it~tni. PAGE OF <br />