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PERMITTEE NAME/ADDRESS 7nrtudr /ucih7r NatrtdLxnban rJlN(~rrrntl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME _ ,_ DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS 1''= <br />PERMIT NUMBER DISCHARGE NUMBER <br />C <br />FAClurv , . MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />- ~ ~ - FROM TO <br />L~rA3G~ WALT ', Pig I`?rr,NF1Gr .< <br />Form Approved. <br />OM8 No. 2040-0004 <br />OHI4rJNIG WET T~5TSNG FfOCi 07.3r~ <br />i <br />~,, <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT _ - ,; .~ . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -.~ :1 :.~ :. .. > :: ... <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r . „ ........ _ _ <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. „ . .~ r.;..; ;,~ .. , .. .. _ <br /> REQUIREMENT ~ ' <br /> SAMPLE <br />• ~ :. ~ ~ MEASUREMENT <br /> <br /> PERMIT ' <br />• REQUIREMENT - c r ; _ v <br /> SAMPLE ~ _ . <br />-''N.~ MEASUREMENT <br /> <br /> PERMIT -r ., r -. , . _ ..., . <br />' _. <br /> REQUIREMENT , ~. P'iR' 'Jr=:' _, i. <br />; Y <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a - ~ - , .. -. _ .., <br /> REQUIREMENT , . - _''•li;" ~-`'.n <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I certif. under prnalq nflao ihnt thi+d~rummt oral all attaa-hment+wcrr <br />ailh <br />t <br />d <br />d <br />di <br />ti <br />i <br />i <br />i <br />d <br />d <br />i <br />d <br />- TELEPHONE DATE <br /> un ur wpers <br />n uccur <br />gne <br />prrpare <br />un <br />er my <br />rcc <br />s <br />un <br />turcr <br />a sys <br />em <br />es _._~ <br />_ _ <br /> m ¢tisurr that yualified prnonnel pmprrh >tather and e+aluale thr infnnnwlioa <br /> suhmiuctl. Rascal un ms inqulrr o! the per+un ur prnum. w hu maw>;e lire cydem, <br />~ ~ <br />_ or those persons direclh rnponsible for i;atherinR Ihr Information. the information ' _ . _ <br /> <br />'- ~ <br />+ubmithd is <br />to the trot of my Atruwkdge and tsrlirf <br />tote <br />accurate <br />and cumpkte <br />J _ <br /> , <br />. <br />, <br />. <br />. SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> <br />• TYPED PRINTED I am aware that there arr si~nificam penultia for erhmittitgp false information, <br />nKludinl the poc+ibiliN of 6ne and imprisonment fur krwwing cirdations. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO DAY <br />COMMtrv 15 AND EXPLANATION OF ANr vwLA I lvrvs IHererence an arracnmenrs nere/ <br />• t._~RE. Sl'AKTIiJG 1-1-09, IF THERE I°.i I <br />i'ORT "NO DISCHARGE" °< GOMPLFTE OU`fFf <br />t~a~E OF <br />