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PERMITTEE NAMEJADDRESS rlndude Fxiliry.Vame/locannn if DifJ'amr~ NATIONAL POLLUTANT DISCNARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS <br />' PERMIT NUMBER DISCNARGE NUMBER <br />FACILITY ,.,~ MONITORING PERIOD <br />.~ is ,: ;' : ;'1 ;, : ; L ...7 :, !_ ri YEAR MO DA YEAR MO DAY <br />LOCATION 1~ D ~ r~ :: rl E' FROM TO <br />:~Y K~r~~l F2ECL!-~i~tATIUPi r~la^ia., <br />Form Approvetl. <br />OMB No. 2~0-0004 ~ <br />tr <br />... ~ x:r <br />laISCHAF~C;E TO Gf2A~SY GFtFLK <br />~. <br />NOTE: Read Instructions before comotetfnq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crnif~ under prnuth ..f law that thin document and idl auachmenn were <br />d <br />d <br />di <br />~ TELEPHONE DATE <br /> pmpare <br />un <br />er m~ <br />ra <br />tiun nr supeni>iun in accurdan.r with a ystrm desigrcd <br /> to asurr (hut yuulilleA perwnnel pneprrh gu(her atwf ryaluate the information <br /> suhmittad. Nusrd un ny inyuin of tier pram ur perMm. who manage the system. <br /> ur thine pennon dirrrd~ rnpunnihlr for gathering the infexma8un, the infonnatfem I <br />' <br /> submiuad is, b. the hest of m. knuwkdgr rod Irlirf, tote, ua-mute. unJ nmplete. ~ i ( <br /> I :nn aware that thr~rt ,rr.i <br />ni~amt <br />multies fur s <br />itti <br />ls <br />h <br />f <br />infor <br />ti SIGNAYURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED ~ <br />p <br />u <br />m <br />n); <br />a <br />e <br />ma <br />on, <br />invludmg for pu,.il,ihr...f (ina :end Imprbonmcnt for Avowing sialutiom. OFjdICER OR AUTHORIZED AGENT AREDE NUMBER YEAR MO DAY <br />v ve~~e~e Vl\IJ ell\V L/a r"LMI\MIIVI\ V! MI\t •IVLMIIVI\J (r1CICl ClIGC tll! tll(tlt:llIIICIl1J IIClC~ <br />~I <br />~I•his iti a •~-j~arf fnrnt. PAGE of <br />