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PERMITTEE NAMEIADDRESS (Inclade faciluv ~'nmdloratinn i(lhffrrrnU NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS - <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY -, i':.i i';E <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ~ ^.! ~' J >'4 ~ FROM TO <br />•~~._ F <! P4TT1=FiGE":!'~F. t_Fi1: P'1~;::!. <br />Form Approved. <br />OMB No 2040.0004 <br />iN I <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> <br />EX <br />ANALYSIS TYPE <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> _~.. ~~- <br /> PERMIT ,, -. ; .If-"`~ " . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT x .~ ~ ~~: a- K , . r .. - <br />t ~ - i- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> :,_. <br /> PERMIT ,~ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ~:. <br /> PERMIT . t. '_ , ' - - ~ ' <br />' <br /> .REQUIREMENT _ :. ; r~L",: _ r <br />i•1 <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~~ c ,. .. ,. ,. <br />~.,. , . _ <br /> REQUIREMENT <br />' ',1;' <br />rl <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 .~nit~ und.•r {,<nau> ~tiaM thu{ Ihi. d.x•umonl analrll alwchmenh w~ _- <br />• TELEPHONE DATE <br /> prrpared undrr ms dtree•tion nr suprrsision in attorAan«• anh a . -stem de.iRnrd <br /> ti,m ~ <br />v <br />t <br />Il <br />mf. <br />l <br />h <br />d <br />l ~ <br />t <br />~ <br />'- C'tl?.r~ . '-:1(1; :O?1 <br />- - rc <br />rnw <br />t K+I <br />rr an <br />e <br />a <br />ua <br />e <br />lu xswrr Ihat y~wLfi d pers.mm4 pruprr ~ <br />~ <br />~ <br /> <br />•~' <br />' : <br />'P <br />- <br />'` <br />t wbmiltrd. Rased ~ n m? inquiry of the prr+on nr prrxms who manag for svtem, <br />amsitelr tnr KatherinQ ihr inGrrmatirm thr information <br />sdtrreth~r~K <br />lhrv <br />~ <br />o a ,' <br />u v <br />~ <br />C~7(l <br />j^?_~j~3t <br />( ~ <br />1~ <br />t <br />Y <br />,- L <br />IF <br />l or <br />a <br />pen <br />n <br />{ <br />•uhmiurd is. to Ibr M•+1 .d m~ Mm.aiedge and Ixlirf. Irue, accuntr. and ntmpkte. ,~~; SIGNATURE OF PRIN IPAL EXECUTIVE , <br />, <br /> I um uwarr that them are siknitkvnl pcnultiee for submfuin¢ false information, ~% <br />THORIZED AGENT <br />R <br />R AREA <br />YE <br />TYPED OR PRINTED inrludinp lbe poasihilin of fior and imprisonment for knowinK siolalions. ~ <br />OFFICE <br />O <br />AU <br />~ D NUMBER AR MO DAY <br />GOMMtiV I, AnL! twrL~arvra t wrv yr .,t.. . t.~~.. ~ ~..~. t..~,.., ~,..,~ ..~, .......,................. , <br />PAGE OF <br />