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PERMfTTEE NAME/ADDRESS r)ncludr F'rxJl(y A'ame/U~catiun iJUiJJetrntl <br />NAME - - <br />ADDRESS " <br />~u;i c;-- <br />_f•1 C ~ L i $~4 <br />FACILITY 1-€flR•I ZtJiti f'i Ih• <br />LOCATION ! j.! '~ r E; 1 4G ~ <br />, :iA1C'F iJAT)F. rrtTrdF Mlar•,iF?,(;.F-R <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPOES) <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 />~R&I`7INE Li•;r <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX S <br />S TYPE <br /> ANALY <br />I <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />-, ~ <br />~ <br />~ <br />7 <br /> MEASUREMENT ~ ~ <br /> PERMIT _ <br />r <br />l <br />, <br />.; <br />- ._ . _ :. : . <br /> REQUIREMENT - ~ <br />' <br />• <br />, ~ <br /> SAMPLE - <br />1 - - <br /> MEASUREMENT - <br /> PERMIT <br />:..; . , . <br /> REQUIREMENT i "''~ ~ ' " <br /> SAMPLE ~ ~ <br />~ <br /> ~ <br /> MEASUREMENT ~ <br /> <br /> PERMIT .. ~ =- ~ ::. _, : _ <br />- <br /> REQUIREMENT <br /> SAMPLE <br />-, <br />._ .... MEASUREMENT -• <br />} ` PERMIT ,.ti" _ - ~ ~;- _ - • <br /> i~~~, <br /> REQUIREMENT <br /> SAMPLE _ <br />~" <br />- ~ ... _- __ <br />~ <br />~- MEASUREMENT - <br /> <br /> PERMI7 ..- r <br />~ - „ „ _ <br />~ _ <br />, i i_ <br /> REQUIREMENT <br /> SAMPLE ~ ,~ , ~ <br />~~- ~,~ - <br />y <br />~ <br /> MEASUREMENT ~- <br /> <br /> <br />- PERMIT <br />.. ; l .•i .- , <br /> .REQUIREMENT <br /> SAMPLE <br />~r' <br />- ~ <br />_ <br /> MEASUREMENT <br /> PERMIT " ., . - ~_ <br />`' • <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I crrli(> umter p~m~dl) ..r law mal lhi+e.K-~mrm and an aun[Ilm~•nl...rrr TELEPHONE DATE <br /> prrpand undrr m. diltcliun or +u{x•ni+ion in a[[ardHn[r with u sslem dr+ipnrd _ <br /> to Kemre Ihxl qualifievl penonnrl properl. I,nuher wld e~aluale lhr infornwtioo _ ^ <br />"- - - <br />_ _ --- - wAmittrd. Itued on m~ inyuir~ u( lhr prrwm nr per.onc who rwna~c the syclrm. <br />erwn dim•tly resprmsible (or I;atherinK lbc inronnaliun, lhr Informallon <br />ur those , ~ <br />_ <br />_ <br />~ ', ~ <br />__ ~-- / p <br />yubmiUed i.. to lhr hr+t of m~ Mnuwlydgr amt hrlie(, lnu, aaruratr, and [umpktr. <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />~ ~ ~ <br />~ - <br />~ - ~' <br />- <br />- I am genre that them are +iytnificanl prnaltir+for+uhmiuin~ fal+e informatiua. AGENT <br />R <br />TH AREA <br /> ri.onment Gx I.nuein¢+iolaliun5 <br />w <br />ihilin of f <br />e and im <br />l <br />di <br />h AU <br />ORIZED <br />OFFICER O NUMBER YEAR MO DAY <br />TYPED OR PRINT p <br />. <br />e p <br />in <br />inc <br />u <br />n¢ t <br />+ <br />COMMENTS AND EXPLANATION OF ANY VIVLAIIUrvs (Hererence an arracnmen(s nere~ <br />_.?M7T APPLT'~r ~OR lOY{~~ 24HR F'RFCIP )`~I1=NT - ~iEE X. A. cam.. <br />Thj. .. ~ ? n art f~,*i~: PAGE OF <br />