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PERMITTEE NAMEJADDRESS ilnrludc Furiliti \amrlf.oratinn if f)ifJnrntf <br />NAME <br />ApDRESS <br />FACILITY <br />LOCATION <br />C gi ; 6:.9` <br />IAIdFFt3E? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />I <br />t <br /> MEASUREMENT •• '- - ~" J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />- <br />' <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 />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I errtir> under prnulh wnuw that mis euanmrnl and all nuwhmrms wrn• <br />i <br />h <br />d <br />i <br />l <br />- TELEPHONE DATE <br /> r, <br />prrpun-J under m. Jintition or super ision in ari <br />artlanar w <br />t <br />u .~+tew <br />s;mv <br /> In r+surc tha yuulifi,rl (w•rvmncl prnptrl~ ttalhrr m,d r, aluatr Ihr informuli,m <br /> +uhmiarJ. NavA oa nq inyuin of Ihr pers.m nr pr r~,n. who munafir the +..trm. ~ <br />~ <br /> nr those person. direrll~ n.pon+ihle La {;uthrrin¢ the informufion. the information • <br /> AnowleAkr anA hrlirl <br />Irue <br />ur orate <br />.md ,~nagdelr. <br />submiltcd is <br />P. the heN of m ' ~ ~- <br /> , <br />. <br />) <br />. <br />, <br />l <br />hd <br />i <br />O <br />d <br />h <br />i <br />6 SIGNA URE OF PRINCIPAL EXECUTIVE <br /> ii.. for +u <br />u <br />~•, nnit <br />•ro. <br />I am aware that there ore siQni <br />c:mt pen. <br />min <br />nt <br />e OF CER OR AUTHORIZED AGENT AREA <br />TYPED OR PRINTED inducting the p,nsibilil} u( fine wnd impn.~~nmrnt for Ano+•in;; .iol;,uon+, NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />form. <br />