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PERMITTEE NAME/ADDRES$ Inrludr /<u llin ,~Omf//~uannn if UiJJerrnU NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPOES) <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 />Form Approved. <br />OMB No. 2040-0000 <br />i <br />NOTE: Read Instructions befor~ompleting 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 /> 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 '-r <br /> REQUIREMENT • ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certih under pewlq Lr INN mm thi. dM111i11•m aml Nu auacllmem` Neff <br />i <br />i <br />d <br />ith <br />U <br />i <br />d <br />d <br />d <br />di <br />i <br />i <br />d TELEPHONE DATE <br /> on or wpen <br />un <br />n accur <br />uner w <br />rm <br />gne <br />prepare <br />un <br />er m~ <br />rect <br />c <br />a y <br />re <br /> to v,cure Ihal yuNlified pe ramnel pruperi) Kathcr aml el alualr 11x• informalhm <br /> suhmiued. Ra.ed Nn m. inyuin of the percan .Ir perwnc Nhu manage the naem. <br /> ur thl..r peounc direc•Ih rngmciMe fur gal tiering Ihr information. the information <br /> whmitted is. lu the AeH of m) knuN hd¢e and ilelief. True. accurate, end complete. <br />~n <br />t <br />I <br />tl <br />1M i <br />m <br />I <br />h <br />h <br />I <br />r <br />h <br />f <br />h <br />f <br />h SIGNATI/RE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED Nnl aNafe t <br />M:In <br />pena <br />tec <br />nf ali <br />ml <br />mg <br />n <br />~f <br />:no <br />. <br />a <br />( <br />ere Nre • <br />QnI <br />:1 <br />inctudinKtircgKCihilit}uffineamiimprnunmentforLnowtngliolatiun•_ <br />OFFI(fERORAUTHORIZEDAGENT <br />AREAI NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Four ?32Q-t iRe~ ~ -,~~.~;'• ,~_li'i_.,. ..,. ~ ~i,'; I illy !..t -~-h;lt-l II'f{tl. PAGE OF <br />