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PERM ITTEE NAM E/ADDRESS +Inc6uk Fucdirv Numa~T.«:uri.+n +f Dr~"emntl <br />NAME ... .. . , . . <br />ADDRESS R G+ ~ <br />FACILITY <br />LOCATION <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. 2(140-0004 <br />NOTE: Read Instructions before comDletinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />_ ~ PERMIT .". y ~ , . : <br />- .- ~i,G„ ~_~ REQUIREMENT <br /> SAMPLE t ` <br />c..l ; :: ~ MEASUREMENT <br /> PERMIT ~ ~ ~' - - <br />- _ ~ ~ ; REQUIREMENT iti,it~~ ~• r•i ,~i- <br /> SAMPLE ' <br />J MEASUREMENT <br /> PERMIT .-, r s.-4r r.' . - ;.I ~ `: -' <br />- REQUIREMENT 'r~1T `• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,. .. -. o:.• , <br /> REQUIREMENT ~ - ~,•.`G <br /> <br /> SAMPLE ` ' ' <br /> MEASUREMENT <br /> PERMIT r :- ~ o ;. +~ x•~iti'•'.: -3E#•# Sc# _ C! ^NY ? fd F! f-l~ <br />t t ~ REQUIREMENT (; :, " i - ~_:'=MT <br />'. SAMPLE _' ; ; -. ,. <br />' ~ ii?U 7 F- ": ~~ ^ " MEASUREMENT <br /> PERMIT = - r.. -' T - r, ~,e..t.-~ ::.. .... ., ., , c- :.. -..ps ~ .. 3 _ f~'.r <br />._ i. t': '. - REQUIREMENT -, • ~ .. Vt l',_~ `: <br /> SAMPLE ° • <br />~•:.~~, ~ MEASUREMENT <br /> PERMIT ,. •- ~ ~ .i., ~,c-c=;~`i' REPOR~i ~ ,,_ - :~i <br /> REQUIREMENT ~ ' ~ DFti I LY r•; <br />NAME/•fITLE PRINCIPAL EXECUTIVE OFFICER I ; anitl tinder penalty a(law rhea thts document and all ntmchment> were TELEPHONE DATE <br /> prepared under me dimtion or supen•ision m accordance with a syam dectgnai <br />S `'; ~l/~y:,v1?tJ to awwre that qualili d personnel properly gather and e~nluatr ttte mfumwWm <br />h <br />h <br />h v_T~ __ <br /> e person or persons w <br />o manage t <br />e syaem, <br />submitted. Bawd on mc• inquin• of t <br />or those persons directly rcspunciblc Cor bothering the in(omtatiun. the inf,nmation <br /> <br />- <br />~ <br />acctua[c <br />and com <br />lete <br />th <br />t <br />k <br />l <br />d lxh <br />L tru <br />b <br />n <br />d i <br />b <br />f <br />d <br />% " <br />! <br />l ~ <br />' _ <br />~ <br />' ~~ <br />r <br />~ <br />~~ <br />l <br />~~ <br />r,; <br />` s. to <br />now <br />ge an <br />e <br />e. <br />, <br />p <br />su <br />m <br />tc <br />e <br />us <br />o <br />my <br />e <br />f <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />-•_i . <br />- - - <br /> ormat <br />alse in <br />on. <br />1 um aware that there are significant penalties !or submitting <br />i <br />• <br />i <br />l <br />f <br />k OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYP OR PRINTED or <br />now <br />ng <br />. <br />anons <br />including the Ixxsibiln} of ime.md impnannment <br />o CODE <br />COMMENTS AND EXPLANATION OF ANY VIVLAI TUNS (Hererence an anacnmenrs Here/ <br />f-iFZ ~' fi <br />EPA Form 3320-1 (F <br />