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PERMITTEE NAME/ADDRESS r(nclude Farilitr Fume/!ia<atinn ijUi/Jrrenrr <br />NAME <br />ADDRESS ~:_ _',;f ;-;.~. <br />FACILITY '~~e P~Ir~~ Cl7Pit'L~x <br />LOCATION -_ ) ~V ~ i3 ~ ~ ~ <br />~' L~FiRfl. r?Ftjl ,tia`ta'ct; .hl rt,snlor~t-c~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB Ho. :40-0004 <br />i <br /> <br /> <br />PARAMETER <br />QUANTITY OR LOADING -- - -- - ~--- ..._.. __ ................ <br />QUALITY OR CONCENTRATION ......~. <br />N~, .r.....,.y ~..., <br />fREOUENCY <br />OF .,,..,.. <br />SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERM-T <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT ~ , <br />.L;.. r,.,:, <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT •~ _ _ <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT - .. ~- ~ r <br />~-: <br /> SAMPLE <br />MEASUREMENT <br /> ~ _ <br /> PERMIT <br />REQUIREMENT _ ~ <br />:~, ~,• ; >: t . <br /> SAMPLE <br />MEASUREMENT <br /> - <br /> PERMIT <br />REQUIREMENT ~ . <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 crrtifl under prnnlq of law that this ducumenl and all auachmcnh were <br />prepunvl under ms direction ur wpenhion in occordancr with a +ystem dswianed <br />- •~ TELEPHONE DATE <br /> was+ure that yunlirisd personnel properly Rather and esaiuate the information <br />submluid. Ra+ed on mr inquiry n! the prrwn or prrvm+ who manage the ss stem, <br />or these Iwrwm+dirrrtk resp~msihle k.r Katherina the in/ormatinn, the information <br />h <br />1\ <br />f~ -J ~-' <br /> <br />~ <br /> <br />_ 1 <br /> +u <br />miued is, to the br+t of my knowledge and helkf, true, accurate, and snmplete. <br />1 <br />h J <br />SIGN <br />R + I / <br /> am aware t <br />at there are significant penalties for suhmittinK false infornation, A / U <br />E OF PRINCIPAL EXECUTIVE r <br />TYPED OR PRINTED <br />COMMENTS AND EXPLANATION OF ONV vlnl imiudinK the po>sibllily of fine and impris~mmem for Avowing +iulation+. <br />nTfnnlc iaoiocar,..e mot, a..~..ti..,....... ~.._..t OF CER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />AFTER i'~~! L~CTit.)IJ i7 x' l? S~,M~L_ES, P;/RMITTEE ,Il^RD TU REQUEST A RFA50NAIILE POTENTIAL ANALYSIS <br />n rnrr~n warn <br />fhi. i~ ,I ~-dart (r,rni. <br />