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PERMITTEE NAME/ADDRESS ilnc(ud~ £dcility .Vemeaorwion iJlhfjirenrl <br />NAME <br />ADDRESS - : l: - • i' <br />E•1 C1:< :i7C <br />i~~N c:r~ tiI r. , <br />FACILITY <br />LOCATION • i~~.nl G d t3 1_ ~~ ~ <br />"~r rcr~r~n. RI`cL.:4r~lA~rtoty MANAGkR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No. 2040-0004 <br />- ,~ ~ <br />:~li~ <br />F - i . <br />DISCHAi~tG~ -'t7 SAC~F CFlE~f''. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />~ - <br />~ <br />~ / <br />' <br /> MEASUREMENT ~ _ / ~/ - ~ /,j <br /> PERMIT -~ - <br /> REQUIREMENT ,' ~ • .[ L <br /> SAMPLE i <br />~ ~ i <br /> MEASUREMENT _ - ' ' - 1 'J - j <br /> PERMIT -- ~' I l . r: <br /> REQUIREMENT <br /> SAMPLE ~ <br /> MEASUREMENT > ~~ ! (,; ; <br /> PERMIT , ~ ,.. . <br /> REQUIREMENT • <br /> SAMPLE I <br /> MEASUREMENT ~ ~ ~ <br /> PERMIT ` ' " <br /> REQUIREMENT <br /> SAMPLE ~ <br /> ~ - I <br /> MEASUREMENT I ~ <br />l <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r <br />~ <br />~ 1 __ <br />~ <br /> MEASUREMENT ` - ' iJ •~ <br /> PERMIT . ~ , - ~ -- <br /> REQUIREMENT - - - ~~ ~ ~ ~ <br /> SAMPLE <br />~ U <br />~ ~ J `- <br />~ <br /> MEASUREMENT <br /> PERMIT ° ~ _ <br /> REQUIREMENT . <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER l crrtif> undrr penaly of law that thi. d~Mlllnrnl and all mtnchmenl were <br />d <br />d <br />i <br />- <br />~ TELEPHONE DATE <br /> trrepurr <br />un <br />rr m~ d <br />rection or .open <br />i+ion in accordancr with a.~ <br />.tem desi);md <br /> a. u+.un• that qualified perwnnd pruprrl~ gatlx•r rnd eruluatc the infonnaliun <br /> +ulnniucd. R:~ don m~ inyuin of thr prrtim ur perwn. who mrnagr thr sr+tem, ,• ~ <br /> ..r lhrnc penonc dinrtlr rr.gm+iMr for gathering tha• ioforma6wt. the infurmmion , <br />- ." <br /> .ubmiRed i.. 4. thr t~ect or mr knowkdgr and belirf, tnte, w-rundr. :mA annpkte. <br />~ <br /> I um aware that their arc+ignificant prnaltie+ for submitting fal+r inrormatHm SIGNATURE OF PRINCIPAL EXECUTIVE i <br />TYPED OR PRINTED . <br />in<•haling the p~n+ihilih nr finr mtd intprhnnmrm for Anowinq +iolalien.+. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />a.vmmu~~.~ nnv ~..r~..~...~w~. yr .+~.~ .w~r~tvt~~ Incrercncr mt atevenrnents Here/ <br />• - ~ - T}11~ Iti d -Z-(lai"t fOf(11. PAGE OF <br />