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PERMITTEE NAME/ADDRESS rl+ed+.tlr Furrltn• Numr.lueation rj IJ+~'+rrul <br />NAME <br />IP.IC. <br />FACILITY <br />i LOCATION <br />~ e z ~~aE3 <br />Af:4~'F? <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. ZOaO"p004 <br />NOTE: Read Instructions before completing this }orm. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREDUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />' _ SAMPLE <br />,~., MEASUREMENT <br /> PERMIT •. _ -.. ..- .. , . :; it-.. ~ ~-'x ~ . i .: r' ' I ..-.:.4~„ <br />_ I` i_ `..' ; .' i -- ; I ~ REQUIREMENT I-I' ;;.,. <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEI'fITLE PRINCIPAL EXECUTIVE OFFICER I certify under Prnah} of Iaa that this dncwrrent :md ull :rttachnrents acre <br />d <br />i <br />d <br />' d <br />i <br />i <br />h <br />d <br />~ TELEPHONE DATE <br />' un <br />tnet <br />on or suer. ivnn <br />n accordance w <br />t <br />Prep;uc <br />rr m. <br />n +} <br />+tem designe <br />' <br /> <br />~~ ` y <br />y~ ~"'~- <br />~ C ~~ to assure thnt yualitied Penrntnel Prnprrl} <br />gathrr and eenlua[c the mtbmwuon -- <br />"- <br />`~ " <br />~ ~ _ <br />• suhmitted. Based mr my inquiry of thr Person or Pcrso¢s who munnge the system, - - -"~' <br />~I> <br />~~ <br />~ <br /> or Uxnr pcrH.as directly reslwnsrblr I'or gaihcnng rho information, the mfkmnnuon / <br />- <br />~ "~ - <br />~ ~ ~ <br />~ ~uhnurt•d r.. to th b.a of m In i~-,t_e and Ix het <br />tnre <br />aecunte and c,~mplere ~ ~ ~-' r- <br />~ / . <br />. <br />. SIGNATURE OF PRIN <br />CIPAI EXECUTIVE I - <br />~ ~ <br />R PRINTED OFFICER oR AurHOai~EO A3ENT AREA NUMBER <br />~ YEAR MO DAY <br />TYPE CODE <br />GVMMtN15 ANU tJIYLANAIIUN yr ANT VWLAIIVNJ (nererence an aQacnmenrs Hale/ <br />''.~ RE <br /> <br />