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PERMITfEE NAME/ADDRESS ifnr61dr Fbci/in \amr/Inrunon if l)iffarnl) <br />NAME <br />ADDRESS <br />FACILITY r~ :: ~ : •. L: _ ... _ ,_ <br />LOCATION , ~{~{ l; L~ E1 l ~ ~~ <br />form ApproYed. <br />f1ATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) OMB No. 2Q40-0004 <br />DISCHARGE MONITORING REPORT (DMR) ~ / <br />PERMIT NUMBER DISCHARGE NUMBER - F ~ I'- <br />- ~,iGt CRE.I h ,, <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY ,~ <br />FROM TO <br />NOTE: Read Instructions before,Eompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREOpUF NCY SAMPLE <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT ~ • <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> <br />REQUIREMENT • <br />~- I -i <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />. <br />~ <br />:r <br />. <br />,. <br />,. .. <br />PEAMIT • <br />REQUIREMENT r' ~ ' <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I rrrlir) untkr prnulq of luw Ihal mi+drrrunu•m and du muarhmrnl, wrra TELEPHONE <br />d <br />d DATE <br />roi~na <br />prrparrd under my dirrctiun ur .upa•ni+iun in accordance with a sT+irm <br />Iu u+.urc Thal yualifiad per.onnrl properl> Kulhrr and e+aluutr Ihr infarnmlinn <br />+ubmitlyd. Hmrd rul m> inyuir} of Ihr prnon ur perwn+ ahn munaKr the +)Hrm, i <br />or Ihn+e pa•num dircctlr resgrmihlr for KatherMg Ihr informulinn, the inkrrmation i I <br />+uhminrd i.. Ir. Ihr hrN of nn knnwlydge and tKlirf, Iola xrurala and enmplrla SIGNATURE OF PRINCIPAL EXECUTIVE I <br /> 1 am nwarr Ihut Iherc an• +iKnifiaanl prnallie+ for+uhmittinK fal+r infurmatian. R OR AUTHORIZED AGENT <br />FI AREA <br />NUMBER <br />YEAR <br />MO <br />DA <br />TYPED OR PRINTED Inrhuiing the p,r+.ihiliq u! fine and impri+,mmrnl fur YnnainK aiulalians. OF <br />CE E <br />COMMENTS AND txNLAlvci I fvrv ul- Alv T <br /> <br />~Alll/1`/J II'7C/C/CII40 l]II oaaaa.r rrrrcrrw rrcr c/ <br />C?O 1 `~: This iti s 4-part form. <br />