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PERMITTEE NAME/ADDRESS!Inrlude Facility .\'ame/!oration iJlli,(/uenrr NATIONAL VOLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS ~ - - ~' <br />j~[);t ~,7ij PERMIT NUMBER DISCMARGENUMBER <br />'.,EN MONITORING PERIOD <br />FACILITY CA f'_~'.1= ~; <br />YEAR MO DAY YEAR MO DAY <br />LOCATION _~EN FROM TO <br />v u ns7rZ ~>_~'~ <br />Form Approved. <br />oMSNo.2~aoooa <br />i, <br />i :;UL'rt _ <br />DcCHG Tp Tc;l}3/tiUBDE1=zSUl~{ UU~_~rN <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX NALYSIS TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ !~ <br />-_ t <br />v4 <br /> MEASUREMENT - ~ ~ <br /> +' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />I <br /> MEASUREMENT ' <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />} <br />; MEASUREMENT ~ <br />~ <br />~ PERMIT ° ' . <br /> REQUIREMENT <br /> SAMPLE <br />~ ' ~ - <br />~ /~ <br /> MEASUREMENT ' <br /> _ <br />, .. <br /> PERMIT ~ <br /> <br /> REQUIREMENT <br /> SAMPLE <br />~ ~ '~ <br />~ <br />1 <br /> MEASUREMENT ' <br /> PERMIT ' <br /> REQUIREMENT -' ' - ' <br /> SAMPLE ;~ , _Z <br />~ •~ J Z <br />~ <br /> MEASUREMENT <br /> <br /> PERMIT . <br />. <br />! I I <br /> REQUIREMENT y <br />... <br />. I <br />- <br /> v <br /> MEASUREMENT <br /> PERMIT ._~ <br />~ <br /> ~ <br />• <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l aertir> under pamalh of law Qwl mi+dur~menl ~nd>ill an~rhmrni+ Mrr< TELEPHONE DATE <br /> prcpand unfer mr dirrrlion ur +uprn i+ion in arcnrdance eilh a y+lrn~ designed <br /> o, a++ure that qunliricd prrvmnd pruperh gather and eauluule the information <br /> submitted. Raa•d on my inyuin or the pcr+1m or perums .ha, manage the s~+lrm. ~ <br />~ <br />~ <br />_..r <br /> rrwm directh resfxen+ihlr fur gatM•ring the information, the Infiermation <br />or th~eu f F ( I <br /> p <br />kt <br />d , - .. <br /> rump <br />a <br />submitted i+. to th< bast of m. Lnowkdgc and belief. true, accurate. an SIGN URE OF PRINCIPAL EXECUTIVE <br /> I um aware that there art +ignifn~um penalties rot wbmitting fal+e information. <br />RIZED AGENT <br />T AREA <br />R <br />TYPED OR PRINTED Including the pen+ibilit~ of fine and imprisonment rot lnoe.ing siolutiun+. OF 1CER OR AU <br />HO NUMBER YEA MO DAY <br />COMMENTS ANU tAYLAIVA 11/Jrv ~r AfVT VIV LMIIVI7J (r1CIC1 CIl{.l: OII OIIObII1IIC1IaJ e/c/ct <br />. .~~ <br />aL.c po;Er.T t f <br />PAGE OF <br />EFA Form 332.• ~q,"; ? cy~ G.ev,~us ~_-, _~ _ - --' T 111 i~ a -l-hilrt turns. <br />