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flndade Facilih A'amdLura(iun iJUtJJrrcnU <br />NAME t~VEL~ <br />ADDRESS : ZO11 M 3 <br />{. v~`i <br />FACILITY ~ ~Qj~ ;+; ) <br />LOCATION <br />t~?J PI`T r_''4 <br />!'iAFdAGER <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 M0. DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />fdE DRNG TftIi3 <br />-~.--" <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 .. ~ t; ~;; rti:' Lt '? t .- . . .. r.- ~ .. . :. :- _ ... T '. :_I. <br /> REQUIREMENT ".• NC? (•~r~ <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiQ undo penalty of law that this document and all at[xchnw•nls weer __ TELEPHONE <br />' DATE <br />prepared under my dirrclion nr +upa•ni+ian In accordance with a system dasiptrd ___; <br />~ <br />• <br />t,r assure thnt yualifiud prrwnncl properly gutlrer and r, uluatr tltr informatbat <br />~ <br />_ - +abmiurd. Bascvt on o» inyuin~ of the pa•t•srm or prrsom who manage the system. I <br />~" - or those prisons directly responsible far yntthrring the information. the information ~ <br />+"" <br />' <br />( <br />~' <br />~ <br />_ ,ubmiurd k. to the M+.t of my Am~wied>;e and belief, true, an~uratr, and complete. <br />- <br />~ <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />• - <br />`- <br />~ <br /> 1 em awarr that there are,ignificant panaltla~ far+uhrnftting falx informatbo. <br />ti <br />n <br />bi <br />i <br />f <br />l <br />l i <br />l f <br />k <br />i <br />i <br />l OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />TYPED OR PR TED +. <br />or <br />now <br />ng • <br />a <br />a <br />including the pus+I <br />oc am <br />mprt+tmnxn <br />a <br />l <br />h o <br />f DE <br />GOMMtIVIS AIVU tAYLArvA1IUIV Vr Hrvi vtv~r+ttvrva (rtt;terent:e au auncnnttatta Ircrta <br />I ra <br />..-cz <br />3G34r fihis is a -3- <br />