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PERMITTEE NAME/ADDRESS (n<(udr F'drififj .Namdroratinn if lhfl'nrrttl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS - <br />$ Q ~; PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY ;~?~j L; MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION : ' FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />~ _ -- <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />__, MEASUREMENT <br /> PERMIT .z ;`• z ">• -~ r- . :_; i < a~ .... - <br />' - ' <br />';; REQUIREMENT i~ll'J :'P.L.L'!- ' •~ <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 /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtih under penally of low that this ducununt and all attarhmems wrre TELEPHONE DATE <br />prrpnred under ms dirertinn or suprn ision in nrrnrdance with a crstem designed - - • <br />'-`-~~ ' <br />t.. assure that yualified penonmi properls gather and rs ulnate the infurnuti~m '- <br />. <br />~ <br />~ " <br />. - - - ----- - --- suhmitted. Rased on ms inyuir) :d ihr prrvm nr prr.:m. who manage the s~ stem, + _ <br />~ <br />- <br />~ <br />or tl+ux prnuns direeti} mpem-siMc for guthrring the information, the Information <br />- <br />- <br />_ <br />~ ~ <br />' <br />=! <br />~, ~ <br />' <br />~ <br />T ! ~ <br />wbmitted is, to ths• hot of my fuwwled¢e and hclief. true, accurate, and complete. <br />- <br />. <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~' <br />~ I <br /> I am aware that there err significant penalties A.r suhmitting fake information. A <br /> <br />O the stbiUtr of floc and fm rEamment for know ht :dutbro~ <br />i <br />ludin <br />g `i <br />~ ' OFFICER OR AUTHORIZED AGENT ODE NUMBER YEAR MO DAY <br />R PRINTED <br />• TYPED nc <br />g <br />p <br />~ <br />COMMENTS AND XPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />:~ <br />• ~i <br />rFA F.~ 3:;L;'-, .R@v i99; _.~_._ -.._,. .. ._ _.___. I ~il~ I~ .! -~-h,;!'! i~+Clll. PAGE OF <br />