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PERMITTEE NAME/AOORESS rlne0rdr Pacilup .1"amr/Locution iJ[hJJarnt) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />CLt 816:3 <br />I:f!>/CTC1R <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 />Form Approved. <br />OMB No. 2040.OOOC <br />~~ <br />>" <br />,/ _~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ... <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certit> under prnalh of Inw Ihal This dllcumenl and all attachmrnl+ wrrt <br />tartd u <br />d <br />m <br />di <br />rti <br />r <br />n in <br />l <br />~ <br />rd <br />wish <br />l <br />i <br />i <br />d <br />i <br />d TELEPHONE DATE <br /> prg <br />n <br />er <br />~ <br />rr <br />lwl o <br />wpen <br />u <br />a <br />s <br />n <br />oncc <br />a y+ <br />rm <br />Ror <br />+ <br />es <br /> to a cure Thal yuali6rd personnel proprd. Rathrr and e+aluatr 111c infnrmmiun <br /> vuhmittrd. Rw+ed un m. inquiry of Ihr prrslln or prrsllns who mana>;r the +~+tem, <br /> Ilr Ihl.+c pf r+lln+ dlrlti 111 rl plln.ddl' fllr Italhe f111~; the InfnrmallUn, the InfUrmalllln I - <br /> whmiuld l+, to the bnt of m~ krN>wledRr and Ilrliel, true. accurate, alld awnplrte. <br />1 ant await IIWI Ihert urr <ignifiraN panaltin for wbmi11in1< false informoliun SIGNATURE OF PRINCIPAL EXECUTIVE <br />' / <br />TYPED OR PRINTED . <br />itnludinR the pos+ihilitr of fine and impriswnmrm for Anowinp .iolmilwlc. OFFICER OR AUTHORIZED AGENT ARp~ -NUMBER YEAR MO D Y <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 332Q-1 (Rev. 3199) Previous editions may be used. Tllt~ IS 8 -1-F1f[ l'c~rltl. PAGE OF <br />