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PERMITTEE NAMFIADDRESS t/ndudz Ftuiliry~ .\'umrJlircafian iJIhJ/}rrntt <br />NAME <br />ADDRESS = ~~N ty ~ <br />7t= <br />,~.- - <br />FACam <br />LOCATION <br />~ I~ ). <br />AitiF,"ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEA MO DAY YEAR MO DAY <br />FROM TO <br />Form APProved. <br />OMB No. 2040-0004 <br />CHf <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br />SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />- <br /> PERMIT -. t ~.. , ~ , . ,.. K t ~i t:.. c .. s a . ...- _ s - ~_ <br /> REQUIREMENT MI\I VALUF: ~ ` ' Y~ <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 /> 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 { n•rtif~ tinder pennly of Inw that mt. d+,cwuent and all atWChmenn acre <br />d <br />v.idu <br />I <br />o <br />da <br />with a <br />.He <br />dr. <br />n <br />d <br />d <br />di <br />~ <br />ti _, TELEPHONE DATE <br /> prrparr <br />un <br />rr m~ <br />n <br />a <br />un ar .ulk <br />n <br />n acc <br />r <br />nce <br />, <br />e <br />m <br />ryt ._ --- _~ <br /> w a+.ure that yunlifiad penunnd prupert. {,retbrr and evulualr tlm infomrntiun <br />- - - -"- r wbmitted. Baud on nn inyuin of the prrsun or pcrwm who monage the .yciem, <br />• <br /> ur tMnr perwm~ dirct1le raapm~ihle fur gathering the htfurmation, lbe inf~tnatinn "' <br />- submitted ts <br />to thr beet o(m~ AnowledRr and tidier <br />true, xcurnte <br />and complete. ~- r I <br />~ . <br />, <br />, <br />r <br />fals <br />1 <br />th <br />t th <br />fa <br />b <br />ltti <br />i <br />fo <br />tiu <br />i <br />ifi <br />t <br />hi SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> am a <br />are <br />a <br />rre urr s <br />gn <br />can <br />prna <br />r.u <br />m <br />ng <br />e <br />n <br />n, <br />rs <br />rnta OFFICER OR AUTHORIZED AGENT <br />TYPED AR PRINTED including the pus.ibiliq of tlnr and impri.onmcm fur Anoain>; ~iulatinn+. CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re-erence all attachments here) <br />.' E <br />. F <br /> <br />PAGE OF <br />7-his i~ a -3-part ti~rm. <br />