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PERMITTEE NAME/ADDRESS Unc(ud~ fari4tr .Yrunr/Lvra(iun if IAjfrrrnH NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />NAME DISCHARGE MONITORING REPORT (D R) <br />ADDRESS _ x u ; ~ ~ •: i . _ . ~ • - <br />r~ ~OX 62L- PERMIT NUMBER OISCHARGENUMBER <br />FACILITY ' i4 MONITORING PERIOD <br />I`iOR I ? tJl\! P i i i•.i ~ YEAR MO DAY YEAR MO D Y <br />LOCATION ,_~ (; ~ ~ ] :; FROM TO <br />( r.r.fr•r {.{[+fSF rr.Tn(1= MAAIOf_`~'F? <br />Form Approved. <br />OM0 No. 2040-0004 <br />- FINAL. <br />P'~MZNE DRIV9 l'ftIII TO 7l;"1'TLE D <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION I~Q, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />_ PERMIT T - Rrf°U`r~ , ,r-•i:a -I v•! <br /> REQUIREMENT u~-lii..'r ^1DNT <br /> SAMPLE - <br /> MEASUREMENT <br />- PERMIT <br /> REQUIREMENT ! .:: ir~¢ ~ `, I H'v" I%i : 'Y <br />.- SAMPLE - <br /> MEASUREMENT <br /> PERMIT -. _. ' # ,; ~ r Ft ~P i7K s IZ t..; . ,. <br /> REQUIREMENT C.,DA r+i/G v~xIL"r ' , - <br /> SAMPLE <br />`~ : `=. `=. <br />i~IT :: ~Li MEASUREMENT <br />._ PERMIT ~~ ;..~. j <br /> REQUIREMENT <br /> <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 1 ccn[fx u~rr pennn) nnuw mat m{s d+><~umrm and ull utWrhmrntx wrm _ _ _ TELEPHONE DATE <br />prepared under my dirntinn w wpentaion in utt~orduncr with a xyatrm datiiRned <br />to aewre that ytwlifnd {a•rwnnd properly pother and rauhwte tM• in(nrtnntiun <br />___ - -_---~_ cuhmitted. f{nxed un my inyuir> of the prrwn or prr.onx who mamRe the xyxtrm, i ~ <br />_ ur lbu.e la:rnm directly rr.p+n.ible (or Ra(hrrine lhr information. the in(urnmtion - ~ <br />' ~ .. <br />whmittrd 6, to (hr heat of my lanuwled{;e and la•licf. inar, aaruratc. and nanpktr. - <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />' <br /> I am nw are (hut there are xi>Zniricuat penulue+ for aubmittin{; (ulu information. R <br />• din the sibiliq of fine and im nwnmrm (or Anowin i luuona <br />i <br />d <br />~ <br />¢ ` " OFFICER OR AUTHORIZED AGENT C <br />pE NUMBER YEAR MQ DAY <br />TYPED OR PRINTED . <br />n <br />u <br />u v <br />p <br />COMMENTS AND~£XPLANATION OF ANY VIVLATIVNS (Heterence an arracnmenrs nere~ <br />RS ~ <br />'v . Derr ., 1 R5v ,!`}~ Pr~wo,.a ~h•vcn~ .. - <br />