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PERMITTEE NAME/ADDRESS Ilnrlude Fa:ifih ~1ime/lorminn if 1lifferenlV <br />NAME <br />ADDRESS <br />FACILITY _ <br />LOCATION <br />'r B ~ ~35~ <br />4A'~lAGirR <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 N0, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ii <br /> MEASUREMENT I <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 />NAMEfTITLE PRINCIPAL EXECUTIVE OFFICER I rertih tinder pa•nau~ ..t ~:a» that this document and all utdu'hma•nl. acre TELEPHONE DATE <br /> prgmrarl under nn din•rtinn nr wpvniJua in aavtrdanm with a .)sh•m de.i>:ned <br /> to a++un• that yuulifitd pervmnd pntprrh K;tthrr and eaaluata• tha• infornmtiun <br /> +uhmittad. fta+ed on m~ inyuir. of the perFtn ur pvnom who mm~a¢e the .++tnn. , , <br /> or lhtne prr+on. AimcU~ n•+{am+ihle for eatherink the infornuttion. the information <br /> and com <br />lete <br />Mvt <br />knual <br />d <br />c <br />nd Mdirf <br />tnu• <br />accurate <br />h <br />itt <br />rl i <br />w th <br />.f <br /> . <br />, <br />. <br />p <br />. <br />.u <br />a <br />•, <br />e <br />. <br />m~ <br />e <br />~ <br />a <br />m SIGNAT RE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED f am aware that Iherc arc aigni6canl pa•nallir. 6.r .ubmittinK falw information. <br />inchtding the pK+ihilih of ^ne and intpri.~auucui Gm AnnwinK aiolWio"+. OFFI ER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Farm 3~2p-i iRev 3r99f Previous editions may be used, Thrti t• il -~-(ldfl fllrlTl. PAGE OF <br />