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PERMITTEE NAME/ADDRESS ilnrludr Furilin G~nteil n+uri<,n i~ lhjjrn rtl i NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEAI ((NPDESJ <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER 61SCHARGE NUMBER <br />FACILIrr MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />F_-~~, Ac .ive0 ~ <br />. ~.'~B Nc+ 2040-Ck~03 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX AN <br />L <br />IS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS A <br />YS <br /> SAMPLE <br /> MEASUREMENT <br /> PEflMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ~ ' <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br />' <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - + . <br /> MEASUREMENT J <br />' <br /> PERMIT <br /> REQUIREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I cend> under pcnaln o! htw that Ihia d~wnmeut and all nttarhment. wve TELEPHONE DATE <br /> pniwrad under my dirrrtion or ,upeni.inn in aceordunce with a .corm dr.i¢ncd <br /> to accara• that yualified perumncl pngx•rl~ L'at her and r+aluate tAe information <br /> arbmittrd. ftased on me inyuin of the pa•rvm or prrwn. who mana¢c the s)•tem. . <br /> or Ihou• pervm. dtrartl~ mta+mihk for gatha•nng the information. thr Information <br /> ~aml co <br />lete <br />I <br />nd• <br />l <br />li <br />f <br />t ~ <br /> +e <br />rue, wcu <br />. <br />mp <br />. <br />,ubmiltad ic, to the I+rrt n! m~ knnw <br />edpv and <br />e <br />, SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> I am aware that tha•rr urr+i>Znificant prnahie. for cuhmiuin>; fake inG+rmuti+m. NT <br />T <br />RIZE AREA <br /> risonment f.+r Am+win_ ci++Iwion.. <br />++..ibiliq of fine and im <br />rludmR the <br />i OFFICER OR AU <br />HO <br />D AGE D NUMBER YEAR MQ DAY <br />TYPED OR PRINTED p <br />p <br />n <br />COMMENTS AND EXPLCinia I Ictrv ur Alvr vw~A I Ivlva inererence au auawunents rtmrrt <br />I <br />{ ~, I`+EASUNA <br />ZrV`y; Prewot+5 c~:if~.,,ns r ~. _, _- I illy i~ ~t ~-I,)Ul ft+l'ill. PAGE OF <br />EPA Farm 33201 IRev <br />