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PERMITTEE NAME/ADDRESS ilnrludr Fatilitr .\'amdlncxlinx iflNfferexA <br />NAME <br />ADDRESS <br /> <br />FACILITY <br />LOCATION ~ 9 <br /> <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 />M~~N <br />rc: t <br />Form Approved. <br />OMB No. 20x0-0004- <br />r., <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 /> 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 /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> • <br /> PERMIT <br /> AEQUIREMEN7 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtiry under i><•ualn ..I lua slut mi+d«umrnl and uu auurhmcnl+»cn' TELEPHONE DATE <br /> preparrd under m. dirrr U..n nr .upa•n i+ion in xcordance wilh u .>+tem Jr.iRned <br /> la J.,wue Ihal quuliflad per.unnd pmprrh Rather and e+aluale the infurmaG~er <br /> +uhmitlyd. Ra+rd :m m~ inyuin or the pa•r+rm ..r pa•non+ ahu manuye the +r+irm. <br /> or Iho.r per+rm+ dim.11. n•+p m+ibla• fur RxlhrrinR the inhrrmatron. the Inturnration <br /> udrmiued i+, a: the hrct ..t m. krwwledRe and la•liet, wr,:Krur Ic. and armplrte. <br />h $IGNATURE OF PRINCIPAL EXECUTIVE <br /> mittinR false infnnnulion. <br />1 am awarr Thal tln•rr ure.ignifieunt prnaltlr+ tr.r w <br />tiun <br />h <br />di <br />i <br />lf <br />ri <br />+i <br />l <br />l <br />h <br />lih <br />ffi <br />k <br />d OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />TYPED OR PRINTED cprn+i <br />n <br />mpr <br />amnen <br />ur <br />nu. <br />. <br />inc <br />ud <br />nRt <br />i <br />ncan <br />nR <br />u <br />+' ( CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here) <br />EPA F^rni ....~0~1 ,Rey -_ p,e:•:ocs arJm~',5 may !:~ ~_-. ~ ht~ I~ a ~ ~+;i r1 I~'IU! <br />