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PERMITTEE NAME/ADDRESS (1ncGdr Facilifr Xamdlgrafuin iJlhJJrrrnfl ti• <br />NAME _ __ ~ ' i i`f I N'o <br />ADDRESS :~• <br />-v <br />~ J V ~ ~ <br />FACILITY ._ i 1 ,~ s.. ` <br />LOCATION t:F~L~:Y. CQ 8Gaf~ <br />~: z I_ ~ =~; : , , ,_ -, ~ ;,a,' ~- rim I NE E 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. 2040-U004 <br />NOTE: Read Instructions before completing 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 />~'~ 1~ <br />'~ T <br />~ I / ~ ('~~ <br /> MEASUREMENT I~ <br /> PERMIT .. ~ .. .. _. _ .., _, ~ - S .. , <br /> REQUIREMENT " ~~ t? r'• l'., ~ AhINI.Jt; _ <br /> SAMPLE L c_~ ` ~( <br />S <br />~" ~I _ ,.~ ~QAS <br /> MEASUREMENT _ ' <br /> PERMIT ~•.. ~ ,,, ,,. <br /> REQUIREMENT <br /> SAMPLE <br />~ _ <br />>` <br />~ <br />• I <br />~ <br />1~"~~ <br />` <br /> MEASUREMENT ' " <br /> PERMIT - .. - <br /> REQUIREMENT iV:: ~:;;: _; ~. ;~l;:•-~;r <br /> SAMPLE ~• <br />~ ~~ ~ ~~ <br />/ r~.QS <br />r" { ~ <br />1 ` C ~ ;~ <br />~- <br />4 1`~ <br /> MEASUREMENT - <br /> PERMIT , Y, ,. r r , r. • : t: . . <br /> REQUIREMENT iG'H A`J^ .,F• : L.`' f" X "•1:~ ~~.1~>, .. <br /> SAMPLE ~ <br />~ <br />' i <br />r ~ ~ <br />~ ~ rl- <br />~ -1- <br /> MEASUREMENT " ~ :~ <br /> <br /> REQUIREMENT f''1:~ '\iUl~!'..'~+ _ <br /> SAMPLE <br />~ ~ ~ 1 - <br />•J • i -y <br />~~ <br />I~ <br />O <br />L"~ ` ~ <br /> MEASUREMENT ~' <br /> PERMIT ~•;r?l~ir i ~ •~~ ~.. -r<~ :.. {-. <br /> <br />' _. <br /> <br />~ <br />. r-~ <br /> REQUIREMENT a' :i)QA AIVC:~ t^•: <br />- .. r' - <br /> SAMPLE <br />~ 1 ~ <br />~ ~ ~ <br />f I <br />r <br />~~~~g <br /> MEASUREMENT ~" I ~ <br />~ <br /> PERMIT - ~ . ._ w. _~ _ <br /> REQUIREMENT _ _'i~~A AVM ~'. •, ' ~ :,IVf~,, <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER { certif. uudrr pa•wlh ,urraw thul ihl. d~nvnxnl and all ouurhmcnt, wrrc <br />d <br />~ ~ TELEPHONE DATE <br /> <br />~j ~- v `k. ` ~,, ~~ -1~ ` i'~ ~ <br />i--`^ ~ ` , ~ prepurad uudrr m~ dim <br />tiau or wpenision in aceordunce with u syztem dr.y;ne <br />to ucwrr Ihul yualiricd•pa•nunnd prnpcrl) {;-rthcr uad a•aaluutc rbc inlnnnalioa <br />Rxrd on m)inyuin of the prrym or perronc who manage the c~stem <br />.ubmiu.d _ r / <br />`- • - _ <br />~~~-~ <br />~ <br />I <br />\ . <br />. <br />or Ihur pe~~.ma dinrUj n rym.iblr far qurhrring thr inforuwtGHi. the inGn-maflon _ <br />~ / ~~ f , (f <br />~ <br />G U / ( <br />` <br />1 <br />\ I a ~~ ~ `~~ ~ -^+T- <br />vvv wbmluwt i+, Io rho la•A or m~ Anowlyd{;c and Ixlirf, IrtK. arrur Ir. and . nngilele. SIGNATURE OF PRINCIPAL EXEClJT1VE ~ <br />~ <br />~ J <br />7 L ~ ~~ -1 ' _~ _ <br /> <br />TYPED OR PRINTED 1 am aware that (here are.ignificunl prnahiea for cubmiUin~ falx• inrormu~i~~n. <br />including the Ir~.~ihilite..f tine u~ impri.anmrnl far AnawlnX a~~duliam. <br />OFFICER OR AUTHORIZED AGENT AREA <br />ODE NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Referenc+e all attachments here) <br />r`- ..:'n: +;__.t F•.. _ - -- I ill i. i .. , ~~ ~. rta tit Vr <br />