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PERMITTEE NAME/ADDRESS tlnclade FacJuy A'amr/l~tration ijDijjrrfnl~ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS - _ _:-F1 : Lii•i 1"' ~ ' <br />WES~f MAIN `~ Th F i PERMIT NUMBER DISCHARGE NUMBER <br />I L~r;t1 <br />FACILITY r: NC I LO CAN'Yl7N M Z tic MONITORING PERIOD <br />LOCATION i (lhl C ~] F: YEAR MO DAY YEAR MO DAY <br />FROM TO <br />~ IZ pllTl l ~I(;'i'fIN. MT NF I'1ftiNA(r <br />:,~ <br />(c <br />F <br />Form Aporovetl. <br />OMB No. 2040-0004 <br />>• ~RruYUly <br />NOTE: Read Instructions before ompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX ANAlYS1S TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT -• - <br /> <br /> PERMIT ~ .... :r :.. L• - _ ;Y- <br /> <br />REQUIREMENT ; <br />; <br /> SAMPLE <br /> MEASUREMENT <br /> - <br /> <br /> REQUIREMENT <br /> SAMPLE ~•~~ <br />~ <br /> MEASUREMENT ~L~~ - <br /> .. ' <br />•' ~., <br />_ PERMIT ,.. . - <br />`_ <br />..... <br />~ ~ `•_ `~ ~'~ ~ . <br />• 1 - <br /> REQUIREMENT - <br /> SAMPLE \ f <br /> MEASUREMENT ~/ -- - <br /> <br /> PERMIT ~- _ <br />`~ `'-e, - <br /> REQUIREMENT <br /> <br />SAMPLE + <br /> MEASUREMENT <br /> <br />PERMIT r- ~. :. ,- ,. .. <br />-- <br />-- ~ -- -. - <br />- <br />_ ".: L'Y M ~~; - - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT is i`~- . r_ ,.,, .. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> .... <br /> PERMIT ,: - _ <br /> REQUIREMENT ?-'f" - ' <br />NAMEITITLE PRINCIPAL EXECUTIV OFFICER l reruf~ nndrr prnalh :dlnw shut Ihi+dncnmenl and all attarhmenl+wrrr ~/ TELEPHONE DATE <br /> prrparvd wider nr+ direruun or m{x•rvi.iun in xcnnluncr with u cydrm Ja+iLned ~ <br />f <br />~ <br />_ <br />i - ~ ~-• ! <br />~ ~~ C, l'_- <br />"` ~I~ /- t, +-'- to aawre that < ualiflyd rwmnrl n. rl1 alhrr and r~:dunlr the information <br />1 fx' P fx' g <br />th <br />+m / ! ~~~, 'i" ~~ <br />,1~ ; ~1 ~ <br /> <br />~ <br /> e y <br />m. <br />+uhmittrd. ffavd on my inyuin ..f the person or prr~n+wh~ manage <br />wmsiblr for gathering the information, the information <br />nr <br />n dina•tf <br />re+ <br />Ih <br />erso _ <br />i /~~ f C y 9~J <br />`/ <br />~ <br />O/ ~ <br />/ <br />~ <br />r y <br />I <br />or <br />~ <br />p <br />t <br />.ubmittrd is. to tM• M•st of m+ knnwhdge and belief, trnc, accurate. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE / <br />- ~ 1 <br />_ <br />'- ~ -'• ~ ~ ~ I am aworr that there are+ryenificam penalUe+f~r whnuuing ful+e information. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED OR PRINTED g . i:datlon.. <br />including the p.r+cihi6ry of fine and impri+onmrnt for Mnowin <br />COMMENTS AND EXPLANATION Ut ANY YWLA IIVrvD (fYererent:e an ntmcrnnCnt~ rrrrr~ <br />l <br />L EF.4 G rr .. r .. - . <br />PAGE OF <br />~llti l~ 8 -~-PArt IY!rnl. <br />