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PERMITTEE NAMElADDRESS rlndud~ Farilgv .~anae!/ncarinn if lhJjntnt) <br />NAME `i{_ ~ _ _ <br />ADDRESS ~- <br />~. t : ~: <br />~" 1--~ S 4'c~ <br />FACILITY -ii_~tZ~~'•`- !!;I•.c_ <br />LOCATION `~ L •_; E: L 4~4 <br />LAt~tGE !H~4T)E, I?I1~iE t~EAhiAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 204p-0004 <br />T T`5TIt <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />- SAMPLE ,- .. ,. l <br />rd <br /> <br />~ , <br />1 <br />,r <br />'' ! • ' - MEASUREMENT O <br />l- <br />_ <br />. 7 L) ~ ? - 1 <br /> <br />PERMIT <br />- : ~' <br />:E :.- <..... ~ ., <br />.. <br />x :. -.... _ <br />. <br />st., <br />s . , . __ <br />~ , .-. s. - <br /> REQUIREMENT .. .. MFa VHL_E ;~ s 'f' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> SAMPLE ~ <br />~ <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 />NAMEffITLE PRINCIPAL EXECUTIVE OFFICER I rrrtih under prnnlh .d law that thi+drw•ument end all euachtnrnt+ carne <br />re <br />an•d under m+ die rtinn nr sn <br />rn ision in w <br />ortlan <br />with a scsi <br />m drsi <br />n <br />d TELEPHONE DATE <br /> p <br />p <br />p <br />R <br />c <br />re <br />e <br />a <br /> In a+wre that qualified perwrmd pnryx•rlr tratlrcr and r+alnatr the information <br /> submitted. fScnrd wt my inyuin of the perwn or penon+ who mw~r the+c+tem, <br /> ar lhmc pen.m+diredtr rnpon+Ibir for gathering the Information. the infnrmalbn <br /> +uhmnted is. to the tryst of m~ wnowiedgr oral belkf, true, accurate. and n,mpletr. <br />I am aware that there are +i <br />nincrnt <br />cnahie+ for +uhmittin <br />lulu inforrnatlnn $IGNATURE OF PRINCIPAL EXECUTIVE ~ <br />' <br />TYPED OR PRINTED g <br />p <br />g <br />. <br />inrludingthclwr.+ibdit~ofnneandimprnunmentforkmrwing.iolaGon+. OFFICER ORAUTHORI2EDAGENT CGJE', NUMBER YEAR MQ DAY <br />GUMMtrv15 AIVU tAYLA1VAlIVrv Vr ArvT VIVLAl1U1VJ (FlEref ef7CB a/l BfrHCllmell(S Here/ <br />1•I1K 15 ;1 -1-~drt f~tNtil. PAGE OF <br />