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PERMITTEE NAME/ADDRESS ilacfude F'aciliry .Yamdl.wntion if /hJJerrnrl <br />NAME <br />ADDRESS •'. c. _:-i'`~~'i i-.•. <br />+.=.rl r::o gib <br />FACIUTr :a r~~rt>~ cot.:~l ;_~; <br />LOCATION ,: ~ ` C ~'• 1 i". _. <br />±/;al~t~, ~'~:.I .-.~AIaT tn:u rtar~at.~~r~ <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (D R) a. <br />PERMIT NUMBER DISCHARGE NUMBER - ~ _ <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE: Rpat1 Incfrttrtinnc halnra rmm~lwfinn this fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY SAMPLE <br /> OF <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />MEASUREMENT ~ <br />„ , r' <br />~ <br /> PERMIT _, . <br /> REQUIREMENT _ ~ , <br /> SAMPLE <br /> MEASUREMENT _ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE , <br /> MEASUREMENT ~I ~ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT <br />~, . ( , <br />I <br /> PERMIT _ t _ <br /> REQUIREMENT ;-;,-, _ <br /> SAMPLE <br /> MEASUREMENT ~ (:' o J ~ D, S ' <br /> PERMIT T-~: i- t-;~:: -r-~ -: .- r': <br /> REQUIREMENT ` <br /> SAMPLE <br /> MEASUREMENT "' ~/ . ( ~ •~ <br /> PERMIT _r - r ~ - <br /> REQUIREMENT _ , , ,° ~..'~;: <br /> SAMPLE <br />~ <br /> MEASUREMENT <br /> PERMIT r , <br /> REQUIREMENT , , <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I a-miry under prnnln o(Inw that thi+dllcumem and yll attachment. wrn' •~ TELEPHONE DATE <br /> prrparrd under m+ direction nr alpenislun in accordance with a c~stem de<iRnrd -' , <br /> to u++urr that yualifird penonnrl properh Kuther \nd c+aluatr for information <br /> submitted. Nmed nn my inquire of thr prrum ur pcnon+ who manp,M the +v+trm• ~ <br /> or 1Mne penoro dirrctlf rcapon+ildc for t;lltherinQ the information, the in/ormatinn ` ~ <br />/ <br /> mbmittad i+, t.. thr Hest of mr knoalydRr and Ixlief, true. accuratr. and compktr. <br />I am auarr that thrrr are si <br />nificant <br />enalti <br />+ fo <br />b <br />itti <br />/ <br />l <br />i <br />f <br />ti SIGNATt/RE OF PRINCIPAL EXECUTIVE <br />'' I <br />TYPED OR PRINTED g <br />r su <br />p <br />e <br />m <br />ng <br />a <br />sr <br />n <br />orma <br />on, <br />includin¢ the p•H+ib{lih o/ firer and imprlsunment for Amncina+idulions. OFFI ER OR AUTHORRED AGENT <br />~ AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />I'•/1^1\aC\ITP A\111 GVrll A\IATI/1\1 A[' A\IV \/IAI wTlrs\In i O <br /> <br />This i, a -1-pa <br />AGE OF <br />