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PERMITTEE NAMElADDRESS i/nrladr FarAuti .~'amr/Lrration if l~if/rrrntl <br />NAME ~:- -- <br />ADDRESS ''~ <br />t <br />eo $~~+~~ <br />FACILm ~7Ff I Znid I`11 f+;F <br />LOCATION ~ Q Ej 1 s}Zq <br />f,~t~:~ WAZ1~, MIfdE w1AP~lACER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />~ - F I i~fil_ <br />~~~.:~~irtilr ~t~~av T~~B ~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />DF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ ~ . T .. - <br /> REQUIREMENT f'1 11~l 1 MUi'" ~• ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~'~ ; ~' <br /> .REQUIREMENT ,:,.. : I; `:,'`' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :` u ~..r .. ~; . .. .. . <br /> REQUIREMENT ~ i'7 X <br /> SAMPLE • <br /> MEASUREMENT <br /> PERMIT 1 .. .. , _ , . <br />' REQUIREMENT <br /> SAMPLE <br />.- ~ ~ MEASUREMENT <br />~. PERMIT - ~~ , -. .~ ,.. -. _ ._. , .. ~ <br />- ' REQUIREMENT ;',C~IiF, r,'•:'G i•li_,`.,:. <br />.._ <br />SAMPLE <br />_ <br />_ .. <br />- <br />.... -.. . - <br /> MEASUREMENT <br /> PERMIT _, . - ~ ,• ~ ,... . ,. <br />-- <br />- <br /> REQUIREMENT ', '`~: <br />':A` Grid ; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT c. - , ~ .. ~ . ~ .. , . <br /> REQUIREMENT ,,~,J,_= _ ^. • <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certify nnder prnuln nflaw Ihm mis d,wllmrm and ull utladlmmh wort <br />i <br />id <br />t <br />d <br />i <br />d <br />d <br />di <br />i <br />i <br />i <br />d <br />d TELEPHONE DATE <br /> prepara <br />er my <br />aae w <br />l a sys <br />un <br />mct <br />on or supers <br />s <br />on <br />n accor <br />em <br />es <br />µnr _ _ - -- <br />_ <br />_ lu araure Ihul yualifird prrkrttnol properly µa1M~r amt e, uluatr Ihr infalmalhln I <br />' ~' '" - „__ +ubmillal. Ra+rd nn m? inyuin of the pcruln or prr+tnl+ whn manaµe the i+sum. ) ~ _~ , <br />' ,- Ur lhl.se pe AOns dlreclly responsitllf fnr ~`a1lMri ntt the infUrmulltitl. the InrUrmellOn ` <br />~ - <br />' i whmitted is <br />to the Iw~sl of my knuelydµe and ha4icf <br />inn• <br />w~curatr <br />mld romldelr ~ ~ <br />/ , <br />, <br />, <br />, <br />. SIGNATURE OF PRINCIPAL EXECUTIVE ~ ` <br /> <br />• TYPED OR PF~INTED I am aware that there are ciµnificnnl penalties for whmiuinµ falx infornlntion. <br />includinµ the pn,sihilih of tint and impriummcm fur hnUwlnR ,inlati.ms. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMENTS AND EXPLANATION of ANY vlut_allvrvs Irreverence an arracnmenrs Here/ <br />:~ <br />.~ <br />I,iri F'ACiF= OF <br />i him i..i {.,Ini. <br />