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PERMITTEE NAME/ADDRESS Ilndudr Focilin A'ameJLor'ariun iflh;(frrenrl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME 1,•, ; _ , • DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS '-'vt~ ~ ~Jr; I`I , ; , <br />Da ~ 13` p PERMIT NUMBER DISCHARGE NUMBER <br />i-A MONITORING PERIOD <br />FACILITY ~~ ~ ,..~~ ~ <br />YEAR MO DAY YEAR MO DAY <br />LOCATION l_A FROM TO <br />I ~nfr ~ L~ra~;: ~ I <br />Form Approved. <br />OMB No. 2040-0004 <br />~E DRlVG TR I D TLS <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />of <br />ALYSIS SAMPLE <br />TYPE <br /> AN <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> MEASUREMENT ~ I - ~~ U r~J~ ~, ~ ~ ~ <br /> <br /> <br /> <br /> <br />~ <br />PERMIT <br />REQUIREMENT <br />SAMPLE <br />MEASUREMENT <br />r- ~ ~. <br />~~~~~! :;'ice <br />_ <br />u ~ ' ~ <br />~, = : ;-- <br />DF= - <br /> <br />~~ ~ <br />''itiu~::• <br />1''ll'Jh•IT` _ <br />- <br /> <br />,..i, PERMIT <br />REQUIREMENT ;-~. ~; ..... (-~F'Cfl F <br />-.e,~ A'Ji~ :'~F'i <br />l.,r. <br /> SAMPLE <br />MEASUREMENT <br />~" <br />/' j` ; <br /> PERMIT : ,:: <br />REQUIREMENT .. - .~T <br />~ `~`~ ftEP'C;? <br />%~~" I ~ -' ~ <br />' ' ' ' ' <br /> <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 /> REQWREMENT <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I certif. under penalh o(Ww thin thi+d~KUmem aml atl anachmrnt+were <br />prepared under m. direction ur +upe n~icion in accortram~r with a ~'slem designed <br />---, TELEPHONE DATE <br /> to auure that yemlified prrsonnel pn~perh gather and e+nluatr the information <br /> <br />- ~ submiltrd. Rimed on m~ inyuirr of Ihr prrwn or prnrms who manage the s~+[em. <br />or thox persons direcU~ re.{ronsihle for guthering t{x infomratiwr, the informaUrm ~ <br />- - <br />• <br />~ ~ - <br />i <br />, <br />' - .uhmittrd i, to for br.t of me knnwtrdge and belief. we. accurate, and mmpkte SIGNATURE OF PRINCIPAL EXECUTIVE , ~ , e <br />, ~ <br />~ <br />' I am aware that them are +ignifkum {x•naltiec for +ubmitGng false inforrnatinn. <br />NT <br />RI AREA <br />TYPED OR PRINTED including the prw+ibiliN of fine and impriwmment fur knowing +iulmium. OFFICER OR AUTHO <br />ZED AGE D NUMBER YEAR MQ DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!l attachments here) <br />:1~':-+t. ~ Sf'lric.i.i a 1-nvrt irtrm PAGE OF <br /> <br />