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PERMITTEE NAME/ADDRESS Unrlude Paci6tt,4cme/Locarinn ijrhJjrrenrl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS - ' <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY , ::_:: ~ '? ,?,~, f•i ;, i~.,y _ yEAR MO DAY YEAR MO DAY <br />LOCATION i,_ A C G ~ FROM TO <br />L.wr~lc~ BADE, ~r.r•:~. rr~r3p~i_ <br />Form Approved. <br />OMB No. 2040-0004 <br />JE t"iRfvG TR ? S <br />NOTE: Read Instructions before completing this form. <br />PARAMETER flUANTITY 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 f. ,: -s - _ ~ - <br /> REQUIREMENT ~., i r.; I (-,,_ ., i°iF', X ;L 1`ili`1 <br /> SAMPLE • <br /> MEASUREMENT <br /> ~ <br /> REQUIREMENT : i? ':` <br /> SAMPLE <br /> MEASUREMENT <br />' PERMIT •- • , ;.;; : mil;- ,` ,. - <br />- REQUIREMENT f; ; sy ; ;tom,:- - .: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - ,_~.. - _,. _ <br /> REQUIREMENT - ail"' <br /> SAMPLE <br />~• ~ ,._• MEASUREMENT <br /> PERMIT F ... ,~ .-'F, ,.. .~~ <br /> REQUIREMENT ~ ~'. DA" <br /> SAMPLE • <br /> MEASUREMENT <br /> PERMIT ~ .. Sr 7 R ... y. - .. i <br /> REflUiREMENT - INS-f i" ~~ ' ^:'a T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT !-:. i., ~ .. _ , : ,... ~ ,- . ,. .. ,. -, - <br /> REQUIREMENT - - ~. t `• .. ~ : i .; a: <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certif. under penulh of la++ Ihm Ihl+doenment and all uttachmrnh were <br />d <br />- TELEPHONE DATE <br /> prepared under m) Jirrctiun or +npenislnn in accordance wish a gslrm desiKnr __, _ , _ <br />- <br />-- <br /> to a.+wrr that yualifird prr.ontad prvprrl> I,ntthrr mut esaltwtr the information <br />_ _~- sabmitlcd. Based on m~ inquin of Iht perwm or persons wha manage Ihr +sstrm. _,~ <br />`- <br /> ur Ih~w• person+dirrctl~ respmclMr car pothering the inrormalinn, lhr informatfnn --~ <br />- <br />~ <br />• _ . <br />' ~- `- ~ <br />~• whmiurd i , to the best of m> knoalydgr and helkl, true, accurate. and cumpklr. <br />SIGNATURE OF PRINCIPAL EXECUTIVE i - ,i ~: <br />~ <br />- ~ '' <br />~ <br />~ <br />' <br />-' <br /> <br />TYPEDOR'PRINTED I am aware Iha7 then arc siknificam prnaltie+frx suhmittinp fal+r infurmuUnn. <br />Indudln the Ibilip of floc and im nc nmem for Annwln i lotions. <br />Ic wn~ P ~~ a+~~ OFFICER OR AUTHORIZED AGENT CRpE NUMBER YEAR MO DAY . <br />COMMENTS AND EXPLANATIVN Ur ArvY VIVLAlIVNS (Hererence an arracnmenrs Here/ <br />1. IMTT <br />Thl~ t, a -~-(~iM fiornl. PAGE OF <br />