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PERMITTEE NAME/ADDRESS Nndude Fadlitc .Fame/LxaNan iJDiJJtrent~ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />LtOy: PERMIT NUMBER DISCHARGE NUMBER <br />i_~~N <br />Facam - ;~ ~ PI 1 ~ i ` ~~.~ MONITORING PERIOD <br />LOCATION I YEAR MO DAY YEAR MO DAY <br />1=N FROM TO <br />, - Kann, RE~.L_;•, ._. <br />Form Approved. <br />OMB No. 2s~0-0004 ~ <br />1 •v~Jii- ~:i_- J <br />~ - F IiVA~ ~L'+•' <br />DSCHC i Q T R I I3 r I7R"r CRD1=K <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ <br />~ ~ <br /> MEASUREMENT / <br />- - <br /> PERMIT • <br /> REQUIREMENT <br /> SAMPLE <br />- ' ~ <br />`) <br />I, ~ ' <br />/ <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l .ertir> nndcl pa•mdl...r law that this dncumrnt and all attarhmen~ »rrc <br />d <br />nder m <br />Jir <br />a li <br />si <br />i <br />n <br />ith <br />s <br />i <br />d <br />d <br />i <br />d ~ TELEPHONE DATE <br /> prrpxre <br />u <br />y <br />a <br />on or wprr <br />on <br />n xcc <br />r <br />xncr w <br />a sy <br />em <br />es <br />gne <br />s <br /> to a++un• that qualified personnel pruprrl~ gattn•r and eaalurte thr information ' <br /> wbmiurJ. Nased on ms inyuin of the penon or prrums wMl manage thr system- ~.r ,~ -. <br /> or (host Ixnons dlrrctly restwmsiblr for gathering thr information, lhr infurmatiam <br /> submitted is, to the be+1 of my knowleJgr and belie(, true, accurate. and compkle. ~ ~ i <br /> niricum <br />I am a» <br />re that thin are sit <br />annltiss for submittin <br />falsr informutioa SIGNAT E OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED ; <br />p <br />g <br />, <br />a <br />including the prrsibilih of fum and imprimnment fur knowing cMlation+. OFFI R OR AUTHORIZED AGENT AREA NUMBER YEAR MQ DAY <br />VVm11n C1\IJ MI`IV CAPLNI\MIIVIY Vr MI\1 tI1VLNIIVI\J II'iC/C/CIIt:C tll/ llllt7l:l IlllCfllJ fIC/C/ <br />~~ <br />_ ' ~! "r'}iis'• is a 4-pa~t'fbrm. PAGE of <br />