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PERMITTEE NAME/ADDRESS /!nclu~k l~ucilrn• A'umu'locanon 1JD/1/crc»Q NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES} <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FAClurv MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE Read Instructions before comoletinq this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />• r- - ,- - ,- i • ; ; _ MEASUREMENT <br /> PERMIT R)::F' (,}R _f- . '.I-;: C_ .: .~ , <br />r ~ -. REQUIREMENT DF; i L Y t•~ Y <br /> SAMPLE <br />r- MEASUREMENT <br /> PERMIT .~ t I •' ... • c <br />_. <br />( <br />` <br />`- REQUIREMENT ~ r. r' ii:='-' <br />F F <br />.~(i <br />.i <br />,•>.I '. ~ ;. SAMPLE ' <br />- ~ _ - h ~, _;. MEASUREMENT <br /> PERMIT - , .: , I.. _ _ <br /> REQUIREMENT <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccru(y under p~-nalry o(Iaw thne thta document ant all utn.hr~nt wcrc TELEPHONE DATE <br /> <br />~ prepared under my Jtrecuon nr supen~tston to accordance wnh tr system r$stgned <br />fp <br />l--~G- ~ f~ ~ 5 ~~rc;G._ to a~surc that yuah(tcd personnel properly gather and evahtate the mfnrmahon <br />submtttcd. Based on m}' tnyuiry o(the person ur perscros who mmugc the system, <br />_ <br />~ <br />_ <br /> the infonnauon <br />or thaKC persons d~realy responsible for gathering the m(ormatian - <br />~ <br />•~ _ , <br />svb»nttcd is. to the best of my knowled c and bchaf. true, accurate, and corn kte <br />g p <br />i <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />I . > - - <br />_ / - <br /> nn. <br />I am aware that there are si~mrficant penalnc~ Ibr suhmitting (also mti>muat <br />f <br />v <br />l <br />ti <br />f <br />k <br />'i <br />i <br />i <br />d <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED P1R PRINTED to <br />a <br />uru. <br />ty o <br />ne an <br />impr <br />scnmcnt <br />or <br />nrns <br />ng <br />mcludmg the pc»itbil <br />l CODE <br />C.VMMtN 15 Arvu tAYWIVNIItJIV Vr NIYT VIVlJilrvr+lA Inr:rcr crrs.c an oacoa.nn+onw ..c. cr <br />~Qr <br />