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PERMIITEE NAME/ADDRESS llnclade FtrlGtr ,tiantt/Location if INJJenrut NAT70NAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />NAME <br />ADDRESS ~ IL;ii i ZIJty M t <br />IIl~k ~ci='S PERMIT NUMBER DISCHARGE NUMBER <br />'-A MONITORING PERIOD <br />FACIUrY HOR Y GL~PJ >`i <br />YEAR MO DAY YEAR MO DAY <br />LOCATION i_A FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />~f*Zt~'I I fVC LRf~v T~ 1 P, T~ TL3 Ti_~ <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF <br />ANALYSIS SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />- SAMPLE I <br />MEASUREMENT <br /> <br />" <br />.r <br />' _ <br />,.. <br /> PERMIT •if•;t-~ <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT ;: <br />r_~'u';.T <br />~: ;: ,~ OR <br />R>f <br />Dr=+ I i 'i "' x ~ ~' <br />.~ : i, _ ' <br />' ' <br />' <br />_ - PERMIT <br />REQUIREMENT ; <br />SAMPLE <br />MEASUREMENT -f'=- <br />T <br />U~2 <br />~ %CIr"i AVCY t1t~ t <br />RE4 <br />DA ~ LY f" <br /> - <br /> PERMIT - - <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT ##+!-'. sr a .~ .. ~ x. _i'GRT <br />~%i~ta r~V~i ~,~~ <br />t; - <br />uF; i t_' <br /> <br /> PERMIT <br />REQUIREMENT ... <br />; :f '~ '` <br />~ ~ <br />Lid • . <br /> SAMPLE <br />MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiry uaader prtmip of m+a that thi+du<ument dmt atl vtrnchnx•na nerr <br />pmpund miler ms dirrninn or suprnidoa in accnrdancr ntth a w+tem da~+lgoad ____ TELEPHONE DATE <br /> <br />- --- --' -- In u++urr that gaaalifiad personnel pnaperlq gather Quad r+aluale the infnrmatian <br />+ubmittcd. Ra+ed on m} inquire of the prn+m or prnasna srhu manage the spslrm, <br />athering the infarmation. the infnrnaalion <br />amsilslr fur <br />di <br />rU <br />n I -, <br /> <br />- <br />_ <br />_ <br /> <br />~ <br /> <br />~ <br />i g <br />ur thane perwaa+ <br />~ r <br />p <br />ra <br />submiasd h. to the best of m. Anowirdge and belief, true, x-curete, and romplNe. SIGNATURE OF PRINCIPAL E%ECUTIVE , ~'"~ - ~ ~ ~ ,U ~ y ~ ~~ (`~ <br />-' "~ f 1 am as+are that them are +ignificam petiaaltie+ fur wbmitting fal+e infnrmaliun. <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED tm9aading the passibUih of fiaar and impri+onmrm fir kmax ing si~dauiua+. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference alb anacnmenrs neref <br />EPA ,~~ _. _ P•e: t - . , <br />a~ =~-pd#r"~`o <br />