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PERMITTEE NAME/ADDRESS 1/nrlu4r Farilirv :Vamr/lraatiun iJ UiQrrrMl <br />NAME <br />ADDRESS <br />- _ ~r <br />~_ ~ I;Cj <br />FACILITY ,-, _ ~-~~ <br />LOCATION ;~(~ ~: ;3 f30~ <br />~~~•~ ,•.t ~a~r ; E~~~~.. O~I•~I. rit <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 />MINOI <br />( ~VB' <br />~ - <br />P['•r~4D <br />Form Approved. <br />OMB No. 2040-0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT _ <br /> <br />.. <br />PERMIT ,. s. ~ -v .~ < ~ . x .: _ .. .. .. ... . , <br /> REQUIREMENT ,fir.,.,;. ,, ,., ~.,,: ~._"•i'-!'i 'i_r,17N <br /> SAMPLE ' <br /> MEASUREMENT <br /> PERMIT #3Trl~#~~ ~ # ;: - ,. _- , <br /> REQUIREMENT •'' -'~' '~`' `' ' <br /> SAMPLE ` <br /> MEASUREMENT <br /> PERMIT . -. ~ r _ .:. r--. r: <br /> REQUIREMENT '- <br /> SAMPLE <br /> MEASUREMENT <br />. <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 />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I . rn~r~ unerr penau+ nnaw that thi+d.KUmem and all attachments wire <br />l <br />i <br />i <br />d <br />di <br />i <br />i <br />i <br />i <br />l <br />h <br />d <br />d <br />- -` TELEPHONE DATE <br /> <br />" <br />~ on or wprn <br />un <br />ance w <br />papa nY <br />un <br />rr m. <br />rect <br />s <br />n eccnn <br />t <br />a+~+trm <br />ec <br />~m <br />111 a++nre Ihal ( <br />UAIitIIYI <br />ennnnrl <br />rn <br />a`rl+ <br />Ylhrf and l`\alii:lll' Ihr lnfllrnlalllro ~ <br />I / ~ / <br />~ i <br />"' ~" ~12i.1~(.'~ 4 ~ I'tun SOI7 p <br />p <br />l <br />Q <br />I , / <br /> +ubmined. fS:nrd on m. imluiry of thr penun or prrvm+ who mana~r the +~+tem. - _ <br />° <br />~ <br />~ <br />L !• t~r . ]'F• { ~ t'..1 ~ ~?L, ur Ihrr:e penun+dirat'll) recpun+itrle fw ~utherinR the informntion. the information "7 <br />.~ - <br />- ~- <br />- ';J`'~ ';; ~ ; _ j, ~ <br />~ ~ <br />~' ~r t'; '' ~ ? `~ ~t <br /> nad <br />th <br />b <br />y k <br />wl t <br />d I <br />r <br />t <br />d <br />t <br />b <br />b <br />t t <br />b <br />f <br />I <br />l ~ <br />~ <br /> w <br />m <br />. <br />m <br />n <br />Kr an <br />re <br />nu urcu <br />e. an <br />cum p <br />e <br />e. <br />r+. <br />r <br />e. <br />e <br />. <br />n <br />h <br />ir <br />l <br />b <br />f <br />G <br />i <br />I <br />t <br />~ <br />i <br />L <br />~ SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED mn au.rr~ t <br />a mat <br />~~n. <br />.d i <br />w <br />n i n <br />ic i t Ih nu <br />t <br />r. <br />~r +u <br />mnl r <br />d. <br />m <br />mclndio;; th. pin+ihrhn ..f fine :md rmpn•,mment for knr wind a datum.. ~ OFFICER OR AUTHORIZED AGENT ARpE NUMBER YEAR MO DAY <br />cUMMtrv i 5 AND txF'LArva I IUrv Ut arv Y vwLa I wrvs (Hererence an artacnments nere~ <br />~T~Illti Iti fl -3-daft f()CiI1. PAGE <br />