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PERMITTEE NAMElAODRE55(lnebbFrWryN~./Lor.eraw(/DIQi..rr) <br />NAME <br />ADDRESS - , . ~ , ,. ~ . <br />FACILITY ~ ~ ~ 1. Li ~ <br />LOCATION <br />-::~,£R ~I CD 8 <br />NATIONAL pOILUTANT gSCHMOE ELIMINATION SYSTEM. JNPDESJ <br />DISCHARGE MONITORINt] REPORT (D RJ <br />PERMIT NUMBER aSCHMOE NUMEER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approv^d <br />CMAB No 2046.0004 <br />~ ~.+F .. <br />„NOTE: Rod Irntructlorr b~1tx~ eWt+pl~th-p t1,~M foam. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• rnEOUENCr <br />of SAMPLE <br /> EX TYPE <br /> ANAlrss <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE _ , <br />- MEASUREMENT <br />~:i7~-JL - <br /> <br />"~~' <br />PERMIT <br /> <br />`' ' :;-~' <br />- <br />~ ' f: ~ , ~"~ F; f __ <br />.~ TGPUR <br />~ i t''_. ~" <br />r <br />= <br />t- REQUIREMENT .,. <br />- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 />AEQUIREMENT <br />t Rn~ry v gene ry o bw tA.t thN dorvment .nd JI at.chmeMe wen _ i i TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER prepared YndH T) dtrxtlon or wprnft/on In .rcordenre wllA . s~etem daltned ~~ /( <br />/ <br />//j ~ <br />j <br />~~ ~ <br />~ DATE <br />/ <br />~ <br />('/ <br />to more that qu.MMei perwnnN Pr~AI [eta end r•dtr.te the Infnnwetton _ <br />~/ <br />,/ <br />wrbmltted. Bred on m. trpwr~ o! the pendt or persau .ho men.~e the .retem. /~~ ~ / /~ /(,Cx ~~ - <br />~ <br />' <br />_ ~~1 <br />or thox persora dl recur reeporolbk for EatherlrK Ue In/ormetlow, the Infonrutbn ~' ~ C/ / <br />_ i wbmlued h, to the best of mr tnewYd~e.nd beMef, irve,.rcvnte,.nd complrte. 810NATVRE OF -gINCIrAI EXECVTiVE I _ _. ~r ~ j / ~ I <br />"- <br />- I bT eweR UU IhlR ere e1~NUclnt pmdfW IOr /11bmlitln~ felw In(Orm.Non, A A <br /> <br />the poedbtut~ of nne.ne Irnprleonrwent ror tnowtn~ .id.tlorrt <br />InrMrdln <br />OFFICER OR AUTHORIZED AGENT NUMBER <br />CODE YEAR MO DAY <br />TYPED OR PRINTED E <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /R~/~r~nc• sN ~ftichm~nts h~r~J <br />=^o ~nrm 33?0-i ~~e: 3'?9i Prrno~~s ed+hnns r"ay h? used .. This is a-1-Marl form ~ PAGE ~ ,. <br />