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PERMITTEE NAME,'ADDRESS !lncludr biu•rlin :vumNZ<>L•otion iJ'DtJ)crenq <br />NAME <br />ADDRESS ilJc. <br />FAC1uTY <br />LOCATION , _} <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDE$J <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 Apprpved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before ompleting 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 />, ; ,~l MEASUREMENT <br />• PERMIT - ~->;iP#~ !: ~ Fl t-'E':;1 ,- 'f - <br />- t: - REQUIREMENT - <br />•I, - SAMPLE ~ - <br />-; <br />~=;--;,.- -:~~?t MEASUREMENT <br />_ PERMIT .. air T ~i^°OF?T _ - <br />,- U?"'.i ',; r<~'..t~: REQUIREMENT .- ±?~:: <br />::.y{_ SAMPLE <br />~~ ~ r: r, •; MEASUREMENT <br />. .. PERMIT -„ . ~ T - - - ~F:AIi <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 «nify under pennln of Inw tl>»t thts document and all attachment. were TELEPHONE DATE <br />,~, -- prepared under m} d~recu,m or xtp`•nuton in accur,tunce with u system ddigncd <br />~ ~~ - , ~ ~~ ~ - ~ <br />~ <br />~ w ~assura that yualifled perwnnd pmperh gather and csaluatc the mlomtutian <br />_ <br />~'~!i <br />~~y ~ - <br />' submits ~:1 Ciused on my inquiry of tlx person or Ixrwns who munugc the s-stcm. - <br /> <br />~ ti <br />~ <br />'^ <br /> or those pers~~ns dircelly responsible for gathering the information. the m(onnunan - <br />~ ~ <br />-_ ~_, <br />` stbmutrd ts. to the best of my knew9edge and Ithef, true, nccumte, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE ~ ? - ~ '~ ('- ~ / i'r <br /> <br />• , 1 s:n .m.,re that there arc stgmticant prrwhie~ fi,r .ubnutnne tale infrnnranon <br />k <br />i <br />l <br />i <br />f <br />d <br />i <br />i OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED R PRINTED u:mc.rm <br />ur <br />tswme v <br />o <br />at <br />ons <br />nxludir.e the posstbdity o <br />fine an <br />impr CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIVNS (Hererence an anacnmenrs nereJ <br />iUObE. I h <br />