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PEHMITTEE NAME/ADDHESS,Include FaeiGfy .\'amdl~uatioa ijINJJrrrnq <br />NAME . <br />ADDRESS _ _,.".r LF <br />.. Ii~_IK: u70 ;fir <br />~'YD£N S`' i:r~ 0163 <br />FACILITY ;.~~~~ ;'ILI~iE (;!]~L~-~ <br />LOCATION ,~~~~~ Lb g1~ <br />;i]Y h(Af7il. `7F'('I I-~?~lA'f'i:IIV f'~4ANAf:FR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />MINOR <br />( SUDR `-C ) <br />F - FIMAL <br />C/5C HC, TO TR <br />Form Apprrwed, <br />OMB No. 2440.0004 ~ <br />NOTE Read Instruciinns hefnra cmm~latinn this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> OF <br />E <br /> EX ANALYSIS TYP <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />M r-- <br />i <br />, <br />= <br />~ <br /> EASUREMENT _ ~ , • <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ~ ~ 1 <br />, <br /> MEASUREMENT ~ ~ ~ <br /> i :u <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~ <br />~ ~ <br />! ~ <br />~ <br />' ~ <br />I <br /> MEASUREMENT . ~ ~; ~ ~ <br />~ ~' / <br /> PERMIT • ~' <br /> REQUIREMENT <br /> SAMPLE ' <br /> MEASUREMENT i ~ i 'I -" -- <br /> PERMIT - ~ ' ' <br /> REQUIREMENT <br /> <br />" SAMPLE <br />i ! <br />~ <br />r <br /> MEASUREMENT - ~ ~ <br /> PERMIT , j <br /> REQUIREMENT ~ / <br /> SAMPLE <br />AS <br />R <br />M <br />'~~~~ <br />( <br />/ <br />~ <br />l <br />' <br />~~ <br /> ME <br />U <br />E <br />ENT ~ <br />) . - ~ <br /> PERMIT ~ , i. ' ' <br /> REQUIREMENT <br /> SAMPLE <br />M i ~ <br />~ <br /> MEASURE <br />ENT ,.,, <br /> PERMIT " ' • <br /> REQUIREMENT - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif7 under penalt. of law that thi+dxament and all atwrhmcnt. weer <br />d <br />f ~ <br />" ~ TELEPHONE DATE <br /> prepan <br />wa <br />er m. direction or wprr+i+ion in accordance with a @Hem designed ~ <br />, <br /> <br />~ to uswre Ihat yualifled pr nonr,el proprrh bather and r. nluatr the information <br />h <br />itt <br />N <br />c <br />. i <br />d <br />d <br />i <br />f <br />h _ i <br />~ <br />H`~ su <br />m <br />. <br />on m <br />ry o <br />r <br />x <br />r <br />nqu <br />t <br />e prrwm or prrvms who manage the ystem. ~ <br />_ <br />~ ~ <br />L <br />J <br />nr these peru.ns dirreth re.pomible for >;atherinT,+fhe in(ormaflon. the information _ <br />_ <br />~ <br />( <br />~ <br />_ <br />rQ l 2~-5~ <br />"~ suhmiucd is, to the hra of ml knowkdgr and Ixlief, true, accurate, and romplrte. ' <br />\ <br />/ <br />I am aware that there are +IRnific <br />nt <br />n <br />lti <br />s fo <br />h <br />itll <br />f <br />l <br />i <br />i <br />f SIGNATURE OF PRI CIPAL EXECUTIVE ( ~ <br /> <br />TYPED OR PRINTED pe <br />a <br />a <br />e <br />r w <br />m <br />nR <br />a <br />zr <br />n <br />ormat <br />on, <br />inclwlin~ the prncihiliq of fine and impriwnmmt (nr Anowing.iolmium. <br />OFFICER OR A THORIZED AGENT <br />AREDE NUMBER <br />YEAR <br />MO <br />DAY <br />--......_...., ........,.....,............. ..... ...,"...,. .. ................. .,...,..~...,...~,.., ,.~,Q, EC I P EVENT SLJ <br />10331 Thi. is a 4 <br />