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PEAMIITEE NAME/ADORESS f/ndtulr Facility A'amr/[.~xurion iJUI•(/rrrnll NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS _. <br />L~ QR ~ :-:.. PERMIT NUMBER DISCHARGE NUMBER <br />_A MONITORING PERIOD <br />FACILITY i-.iCi~ x ~Lii~ i'i i ivsr <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ` A ` p i.. FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ ~ ' ~ ' <br /> MEASUREMENTi <br /> PERMIT ,, :- -- ,; R P at.. <br /> REQUIREMENT ;3iJDA AV~~ DA I l Y' M F' F~fl^' ~ '~ <br /> SAMPLE ` <br /> MEASUREMENTI <br /> PERMIT ~ - ; ~ ;: ~z ;, .z n ;..~- ;, ~ ~r CsR 7 _I i~ <br /> REQUIREMENT ='GL~A AVG DAILY' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x•adr•ri t: I .tC I ,~.~. <br /> REQUIREMENT ~~` I'+ ~. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .t : - r .~. I s - <br />„ . REQUIREMENT ,;~ ~•;V ~~ - •, t ~_~~, ~ . ; <br />' SAMPLE <br /> MEASUREMENT <br /> PERMIT r .~ ?t # , . .;. _, ^ :~- +t. <br />- ~ REQUIREMENT ~ 3(?GA A'a/G CF, T l : . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :.; k x . , - ~ r , _ . <br />- .. REQUIREMENT .~ .t '•~DA Ati'G ~ ~-~'r l -Y I`^ X :.i. ;~ <br /> SAMPLE ~ - ~~'~~ ~' <br />- MEASUREMENT <br /> PERMIT } ~ ;;.. , .. ,. .. r ...- _ . <br /> REQUIREMENT -~<~DA AVC' 1;F, "tY Mrlr', - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ~., t,r> wtdrr prnaha or law that this doattnent and all attachment, were <br />Ylo <br />r <br />Ai <br />w <br />w• <br />idun I <br />orda <br />c <br />xith <br />dr <br />i <br />d - <br />A <br />d <br />U TELEPHONE DATE <br /> p <br />eps re <br />un <br />rx <br />n or <br />l <br />n <br />n acc <br />e <br />a y <br />rm <br />+ <br />gm <br />- <br />er m} <br />n <br />- <br />~~ <br />- to assure that yualifird prru:nnc! prprrly Qathrr and esahmic tlu information --- - -- --'~` <br />'" "'' ' <br />` <br />l submitted. Based on ma ittyuin~ of for prrson or prrwna who munatCe thr system. - .. <br />~ <br /> or thine perwn+Airrrtly repomiMe fur Katberityt [hr information. the information - - <br />~ -~ - <br />~ ~ ~) _-- <br />whmittcd i <br />w th <br />beat ~A m <br />knowlyd <br />e and laiirf <br />true <br />uirurutr <br />unA com <br />lete <br />' /~ <br />' ! <br /> y <br />g <br />, <br />, <br />p <br />. <br />; <br />e <br />. <br />, <br />, <br />SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br />I am ow are that (here are siXniticant penal6~rt for wbmittinR !also inGxmutiun. <br /> <br />e <br />P AREA <br />OFFICER OR AUTHORIZED AGENT <br />MBER <br />TYPED OR <br />RINTED incluAin>; the pos+ihilih u( tint and mtprixmmrnt rot knowink sirdutian+. <br />YEAR MO DAY <br />CODE NU <br />L.VMMCI`I1J NIYU CAYLNIYNIIV fY Vr NIYT vlV tJi1IVIYJ Irtererence rllr tll(tl4/1IRtlI,(J rrClC/ <br />)00.7+. ~Illl <br />