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PERMITTEE NAME/ADDRESS rlnclr.Jc Fcxelin~ Nume/Locunnn rjDiJjeremj <br />NAME <br />ADDRESS ',jlj~• <br />:ELY . tJ " : f., =-~ I' <br />FACILITY {{~~ ,_ <br />LOCATION sELY ., .. ~ t`., ~.i %.: <br />,,~+! J. ~ ~ 1'--'--F•tF: {, f., 1:1+~E MAPtAGF_R <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. 2044-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, fREDUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ' ' I <br /> MEASUREMENT <br /> PERMIT .. <br /> REQUIREMENT - <br />r•. ~ r <br />• <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under pennlty of Iaa that this dixument and all attachmenic were TELEPHONE DATE <br /> pn:pared under m} direcuou or supenniun m accordance with a system devigned <br />~ i-, ___ --- <br />,) ~ G ~• % -- ~ ; . '" ~-_' ~ w asurc that yuahtied pertitmnel properly gather and e~~aluate the mformauon <br />.vbmitt d. Based on my inquin• of the person or pcrcros who mutaee the system. _ _, <br />~r ~~ - <br />~ <br />~ <br /> or tM~se pawns dirrctlc rapuacible fur gathering the infnrrnanon, the mfonnation -^-~ <br />~ ~- - - <br />- <br /> <br />~il -. <br />i r'uhnutted ts. to the hest of my kn~•~olcdee and he!,et: true sccuraa•. and rnm ?rte <br />p <br />r <br />ht , <br />I <br />n <br />~~ <br />t t~ <br />: <br />o <br />du „r <br />, <br />t ~~ ~ <br />h <br />SIGNATURE OF PRINCIPAL EXECUTIVE i <br />._ <br />- <br />~ 7 ,~ <br /> <br />OR PRINTED <br />E , r; <br />,r <br />, <br />v: ! <br />r t <br />, <br />. <br />. <br />. <br />.i <br />e <br />•t <br />hi? <br />h <br />i <br />~ <br />~ OFFICER OR AUTHORIZED A.~ENT FREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYP <br />D n., <br />in : <br />n ~ . <br />n t.,~ <br />r.,pn r,,~...: <br />,c h•~-.i <br />• r _ i CODE <br />GUMMENTS AND EXPLANAI IUN ur ArvT VIVLAI wrvs (F(ere/ence an arracnmenrs Here/ <br />,tR PRFC { <br />EPA Form 3320-1 (Rev. 3;99) Previous editions may be used. <br />T1TJS JS ti.~-f)&rt tOrlTl. PAGE OF <br />