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PERMITTEE NAME%ADDRESS NrxlerJe Fac•d(n .e,tmt'lnruriun gDiJferenu <br />NAME <br />ADDRESS <br />- *- <br />FACILITY <br />LOCATION . <br />NATIONAL POLLl7TANT~DISCNARGE ELIMINATION SYSTEM (/VPDES) <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 />pMe No. 2040.OOOa <br />X <br />NOTE: Read Instructions before comoletin4 this form. <br />PARAMETER <br />O <br />I <br />NT <br />A NO FREQUENCY SAMPLE <br /> QUANTITY OR L <br />ADING QUAL <br />TY OR CONCE <br />R <br />TION . OF <br /> ~ TYPE ~ <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~."R '-i'~ MEASUREMENT <br /> PERMIT <br />- ~ ; :-? - . I ~ REQUIREMENT i <br />• SAMPLE i <br />!L ;.' ~,r ; ~_- MEASUREMENT <br /> PERMIT a .r - <br />` ` " '._ ~,.li:'•i ~ `~ Ai._U: REQUIREMENT <br />• SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ t :t f -:~ a .,_tf' T ._ :~!° <br />,:.I - _ REQUIREMENT <br />• SAMPLE <br />- ~r;~_ =r,.~:c_r_', -; . MEASUREMENT ~ <br /> PERMIT ~ ~ ~ it - !- .: , _ _ ~ _, 1' ~r'A13 <br />- ~; (•,j" REQUIREMENT _, <br /> SAMPLE ~ ' <br />i i! ; Fti~ F2"~ -,,; • , ,-' ~'-, ~;1-" .. MEASUREMENT <br />.'c'=! `_ PERMIT ..:~:; - i `.i:' F7EF'C!!' 1" ` ~.+''F:. a+R~i: <br />- r ~ ! .IJI-!' ~~Nrt°S `J ~;_ ~ REQUIREMENT ~'.•~%L"+~ A`.' nF, : t_.., I . <br />' ' SAMPLE - <br />_. - - ._ .'•v'E,< ",:',: i MEASUREMENT <br /> PERMIT ,•..•tt-~ REF'C1F!T i~'Fp`~RT .. ,, <br />- t' _ -.c:yc REQUIREMENT r . r.i ~: <br /> SAMPLE <br />- = - ^_; 2 (-L3l_ ~ MEASUREMENT <br /> PERMIT y x~ a ~ °E~'f]!~ ~ ~' LP •:;I ..,_ •`, '. <br /> REQUIREMENT ,... '`f-- ; ~ '•' <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I .crnry unJer penalh nC lain that this dcwwnrnt :mJ all atm.Funenrs sere <br />J <br />d <br />- <br />d <br />ti <br />vi <br />J <br />d <br />i <br />h <br />d TELEPHONE DATE <br />_ _ <br />'~, ~ ~ -may ~, _ ~ un <br />rrcc <br />un er supen <br />pc <br />parc <br />er mp <br />un m a.cor <br />nnce µ <br />a sy+trm <br />es~gnr <br />t <br />to assure that yualificJ Ixrsonnel properly gather and evaluate the inlunnatinn <br /> <br />' <br />submnud. Buse) on my inywry uRhe person ur pcr~onti w ho manage the syaem. . <br />.-~.v- - ~_ - " <br />~~- _ or thus: perwns Jirri4ly reslxxtsible Cur gathenng the mfurtnation. the inlormauon - - '-~ <br />- ~ <br />- suhmnt <br />J iy <br />to th <br />tx <br />r of <br />ai <br />m kn <br />d h <br />b <br />f <br />d <br />w <br />• <br />t <br />d <br />l <br />t ~ <br />~ <br />- <br />~ ~ _ . <br />c <br />r <br />s <br />r <br />u <br />e <br />ge an <br />e <br />e <br />. <br />e, a. <br />ruru <br />e• an <br />comp <br />r <br />e' <br />I ,m ,.~ <br />:rr :hr,c rho*~~ arc srgnrficant prnalncs Im subrmumg false inCormanon SIGNATURE OF PRINCIPAL EXECUTIVE ' ~ _ _ <br />- ~ <br />` <br />TYPED OR PRINTED , <br />. <br />ra I :u~r._ thr 1~ ~.ihdr... „f tine and impnsnnment Cur knuwmg vulari"ns OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> . CODE <br />~.~. ~~ <br />EPA Form 332p~1 (Rev. 3199) Previous edkwns may be used. , ;; ,n Tf11S 1S 3 4-p3Tf IOfill. PAGE OF <br />