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PERMITTEE NAMElADDRESS tlncfuAe Fxitlty ~'amdLacatinn if A)frrent7 NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D RJ <br />ADDRESS <br />~ Q ~ PERMIT NUMBER DISCHARGE NUMBER <br />~^~ E {'I - MONITORING PERIOD <br />FACILITY ~_ L A ~,~ I ~,;E ~ ~ YEAR MO DAY YEA MO DAY <br />LOCATION ~~N FROM TO <br />,r a .cur ptr- - <br />MINOR <br />F --~ F I DIAL <br />D5G I-iG TO TR I B i r I 5ti <br />Form Approved <br />OMB No. 2Qp0-0004 ~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> aNat.rsls <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~/ . <br /> <br />MEASUREMENT r <br /> <br />PERMIT -,.; <br /> REQUIREMENT <br /> SAMPLE ~ ~ . ~ C i ' :) , •' Y <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> <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 />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I crrun under penalq of law that this document and ail utwchments weft TELEPHONE DATE <br /> preprred under m. dirertioo or wpenision in xccordxner with a sT+tem designed <br /> to assure that qurlified personnel pmperl~ gather end erduate the {nformrtion <br />submitted. Based nn m. inyuin or Ihr person ur pawns who mrnxge the system. <br />or those persons directh rrsputniblc fnr grthrring the information. the Information <br />~ a <br /> <br />~ ~ <br />--, <br /> vthmiued h, ua the best of my knowledge and belkf. true, rsturate, end complete. SIG ATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I rm xwarr that there are signillwnt penaltks for submitting frlse informrtlor, <br />including the possibiliq of fine and Imprisonment for knowing vi~9rtiuns. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />GOMMtrv15 ANU tJkF'LAIVAIIVrv tJr ArvT vtvLwllvrva Inererrrnct: are ullacr/IIICIIIJ rlt:re/ <br />Ran Tfl RFf3iIF_ST r, {?FASONABLB PtJTENTIAL ANALYSTS BE <br />Thl~ i~ a; '~-n;tr•t !'rlnn„ PAGE OF <br />EoA Fnr^i ?32C~' 'Rev 3,'99 Pie.~ocs Gdw- s r-a. __ - <br />