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PERMITTEE NAMEIADDRESS rhKludcFccllirJ~,tiamNl«:mlunlfDl1jrrrnp <br />NAME <br />ADDRESS ~,;'. 1 r,!,~ <br />FACILITY <br />LOCATION , <br />`_ l~ ~' ; fi ~~i <br />hfAdVA:: Ffl <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. 2040-0004 <br />~S <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION Np, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ;.: ~ ~ - - - - . L / , c{ ~, - <br />~; ~!: REQUIREMENT - I'ir ~!`-+T1= <br /> SAMPLE ~ <br /> MEASUREMENT <br /> PERMIT , , 7 q <br />I ;. ~ REQUIREMENT I , : ~ - ;~i :; ~ - <br /> SAMPLE r - <br /> MEASUREMENT <br /> PERMIT r- ; t <- „ ,: - <br />" REQUIREMENT •:if; <br /> SAMPLE <br />~ MEASUREMENT <br /> PERMIT - ~ ` <br />ti`~L-IJ[ REQUIREMENT - <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT - <br />- ,~,- REQUIREMENT _; ; !n;a,?; <br />: SAMPLE # ~ r <br />C;~i:l,,l •I"F?~~lT! `.J? FL',''a MEASUREMENT <br />' PERMIT - -: e..:.k :- ^- ~•+; ~?i< .. ~ , r ~ 1i•1t-,.- 'v :3 ~'i <br />r- -• ~ _.. REQUIREMENT c ~•'.~ ',~ : ; ~ <br /> SAMPLE 1 `~ ` <br />- MEASUREMENT <br /> PERMIT f?1=I'OR' ~ ,; _. ~,= <br />~' REQUIREMENT •. - T~v - <br />NAME,TITLE PRINCIPAL EXECUTIVE OFFICER I c_rur. under pewlty :,i !au that this dcKwnrm end a!I attarhmcnra werr <br />r <br />t <br />d <br />d <br />d <br />i <br />i <br />~ <br />d <br />ith <br />J <br />i <br />d TELEPHONE DATE <br />_ <br />5~~~ /~ <br />.. , i,,~ i~ ~ prepare <br />un <br />er my <br />vice <br />~un or su{wrv <br />s <br />on m ar <br />cor <br />nrsec w <br />a }s <br />em <br />c+ <br />gm <br />to assure Ihut qualifies !xrw>nnel properly gathrr anA evaluate the infmnation ~_ - <br />- <br />L submitted E3axY1 on my inquire of the person ar perwns who manage the system, ~.~'~- ~/ " <br />~ <br />~ <br />~ <br />f or those persons dire+,tty mvpnrt ible rnr gethcrmg the m(ixmmion- the mfurmauon ~ i <br />- ~ G <br />.~' <br />' <br />I <br />~ <br />; <br />!% <br />! b <br />t <br />th <br />f <br />d b <br />ui d <br />~ <br />t <br />k <br />l <br />d <br />! <br />f <br />t <br />d <br />l ~ ~~ <br />1 ~ <br />: <br />. `~ ns: o <br />now <br />su <br />m <br />i <br />. <br />o <br />e <br />my <br />e <br />ge an <br />e <br />te <br />, <br />rot, aicurate, an <br />comp <br />ete <br />1 am aw;ar ,~~.~~ tl~c:r .vo <br />.ignrficanl pcnnlricv Ibr submittin <br />raLsc inlormanon SIGNATURE OF PRINCIPAL EXECUTIVE •~ .-.!>~' 7 C <br />- <br />' <br />TYPE R PRINTED . <br />g <br />, <br />includin <br />die <br />~•„~h;hr: ,:f IInC and ImpIISORTCm rot knoWin <br />VpllarlOlrG QFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> g <br />r <br />g CODE <br />GUMMtIV I, ANU txYLANAI Wrv yr Hn>• vtvrlat Ivna Irtererence au aaacnmen[s Here/ <br />• -; P, P <br />is is a 4-part form. PAGE <br />