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PERMITTEE NAME/ADDRESS ilnclude Fxifiq A'antr/lrrarinn if Uifftrenll <br />NAME .. . _ <br />ADDRESS <br />•+24 <br />FACILITY <br />LOCATION ~c4 <br />~r.lrr ,-, r,s~c rr,inle: M~tUAa~i~e7 <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 />iE: I?RtJG TR TD <br />~•:,_ <br />NOTE: Read Instructions before completing this form. <br />Rt=~ I <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br />EX FREQUENCY <br />of <br />ANALYSIS SAMPLE <br /> <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT ' <br /> <br /> PERMIT <br />REQUIREMENT " <br />~ i f.•"; <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 /> 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 a'a'rUf~ under pcnalq of law th~t,hi. document and all attachment were <br />prepared utxler m} dirrdion or +uprrrisian in nccnrdance with a wvtrm designed TELEPHONE DATE <br /> <br /> <br /> <br />- --- - ---- - - <br />w awwre that yualificd pcrvmnrl pr~yxrl~ gather and eaalualr the inrormatlnu <br />.ubmittrd. Ila+ed un n,. Inyuin or the IKrwn ur prrw,ns who manngr the scstrm. <br />uo.ibk !w gathering tbe information, the inrxmnUan <br />om dirccU <br />rec <br />thine <br />e -. `_ <br />' <br />i ;t1.~--~ <br /> <br /> <br />1 - ~ 1 J <br /> <br />/ <br />i . i~ <br /> <br /> <br />~ <br /> <br /> <br />( p <br />or <br />p <br />n <br />~ <br />submitted is, b. the hnl of my knowhdgr and belief. true. uccurnlr, and cumpkte. <br /> <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ _. <br />u <br />~ ~yS ~ i I am aware that there ere signifia,nt penalties far submitting fate infnrmation. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED OR PRINTE including the pnsibitits of fine and imprisunmem Gar knowing riolauons. <br />COMMENTS AND EXPLANATION OF ANY vIUL.Alwlva trrererence an arrecrnnrnw nee cl <br />If ~ <br />This is a 4-~att form. PAGE OF <br />