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PERMITTEE NAME;ADDRESS ilnchrJ<~ Facilin Name'l.rxnrum ifDi,/Jerrru/ <br />NAME <br />... _ i , . <br />ADDRESS <br />:,,r~ <br />FACILITY <br />LOCATION . ; ~ I. i <br />'ri 82~4F? <br />i~1AP•:ArsEft <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 />;~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREDUENCY SAMPLE <br /> <br />~ OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT a it~.f"' <br />t- REQUIREMENT - ~ I <br /> SAMPLE <br />- ~ MEASUREMENT <br /> PERMIT „t _ , <br />- ~ ~,_: - ~;..,;, ,-• REQUIREMENT <br /> SAMPLE ' <br /> MEASUREMENT <br /> PERMIT .i-, ,. ~ ~ - <br />,., • ~~~' <br />REQUIREMENT <br /> SAMPLE <br />-~• _ ;; - MEASUREMENT <br /> PERMIT ~ `'. ~ ~ ::'F i= - . ,. ;F?Gtr_. <br />= iJ.Jr-f.~ ~ - REQUIREMENT .. `•-,",, <br /> SAMPLE <br />r~ •! p,L n ~ :- MEASUREMENT <br />I ~ •~ PERMIT :r~.. tr:. • ~'+~p~'!''1' :_-.-'iJF ;T: ._ : ; A.' <br />- ~- l v %'_:~: '~ . F} C;! : ' • REQUIREMENT _ . f?At 11_ Y <br />'~ :7{'i : t}i'; SAMPLE <br />fUTAL. RF•: CVERA,='.. ~= MEASUREMENT <br />" ~` ('• f) PERMIT it4» .. ,.EPGlFdT i~FF'f.334T ; ! t -F'A'_ <br />:c c- :: , ~:-..:: =~; 7ss -_ REQUIREMENT ;r?DA r-'t'!~ !'•~~ 3'_ ,.: 1 ~., <br /> SAMPLE <br />: ._ _"- . '. •`~ ~R A~ 2' '- MEASUREMENT <br /> PERMIT :-~`.7i? ' !.i:a'ni,'•r i t:;. `' <br /> REQUIREMENT ' i.: ; ~ •~ • , ,- <br />NAME/TITLE PRINCIPAL EXECUTIVE QFFICER I ccndc uodcr penalty ,~I law that this d.kununt and all art~.hmcnts wctn TELEPHONE DATE <br />_ _ <br />' prrp:urd unJer my duccuuo ~.r sulxn~ ton m accon]nnce wrth a ti~+tem d ~tgnul <br />~_i/ ~r ,-_, ~ , , .i - <br />// In assure that yuahhed Ixrsnnncl propcrl~ gather and cvaluxtc the inh,rmatum '~- <br /> <br />,ubrtutted. Based on urv myuin of the person or pere~ns w•ho rtumagc the ,waem, _ <br />-~,~~! <br />~"` <br />~~ <br />~ ur those persons dircv,tlp respomiblr liar gathcnng the informution. the mGxmation _ <br />'~ <br />- - <br />-- <br />~~ j /;!~ iuhmitt~ d i~. to ilte best of my ktr~wfcdge and bchef. true, acruratc. and complete. <br />~ <br />! orn <br />• <br />th <br />t th <br />ln <br />f <br />l <br />fi <br />t <br />f <br />b <br />itu <br />f <br />U SIGNATURE OF PRINCIPAL EXECUTIVE ~..r `• = C ~' <br />~ <br />TYPED R PRINTED .:. <br />.; <br />r <br />a <br />ere arc ~tgn <br />cart <br />pena <br />or su <br />ng <br />cs <br />m <br />a <br />se m <br />ormu <br />nn. <br />n~i' i!:nc thr pusstbdny of tine and imprisonment (or knowing violations QFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />AND EXPLANAIIUN Uh ANT VIULliI IUNS (HerereflCe 811 8rf8C/lmenrS heIBJ <br />i~I-This is a 4-part fo <br />