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PERMITTEE NAMEIADDRESS Undudr Farilitv.~~amr/Lutation;Jthjjtrtnt) <br />NAME ~U~1, ~.~._~- <br />ADDRESS ' <br />L~{3~1 - <br />__~ •.. .O ~ I$~'~'i <br />FACILITY tiOR ~ 7 `_7N ? ; ':_ <br />LOCATION ,_/=1 f (J ~I $~4 <br />f-AIV('E WJdTJ~. MIIwE ilAf~3AC?ER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDESJ <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY. YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />lel - 1 M 1 1=tt 3 rl <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 />~ <br /> MEASUREMENT ~ ( ~ ~ ~ ~ ' <br />' ~ <br /> PERMIT ,-•a#~4r -, ~ a,r~: - - ..-. _. _ ._ <br /> REQUIREMENT `"I I fu I !°i: "~' ''~ <br /> SAMPLE <br /> MEASUREMENT - <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT • <br /> PERMIT L~ ~ _... _ <br /> REQUIREMENT - ~~If', ~i (Z :- , _t t) L- ~.~ ' urn ' i . <br /> SAMPLE • <br /> MEASUREMENT ! ~ `' • <br /> PERMIT > , , .. .. _,- .., ~ L, <br /> REQUIREMENT ~. , : ~:• • • • ~ _: <br /> <br /> SAMPLE <br />~ <br />~ <br />-,+• MEASUREMENT . <br />- PERMIT <br /> .REQUIREMENT 3G'DA ,'+` <br /> SAMPLE • <br />~ ~ <br />~~ ~ <br /> MEASUREMENT <br /> PERMIT ~ ~ ~ • <br />- REQUIREMENT '.•i3gFl F, .. ; r L •f ''i ~ <br /> SAMPLE <br />Z <br />^'` <br />~ ~ f <br />• MEASUREMENT ) ~ <br /> PERMIT ., .. , ~. _. - <br /> REQUIREMENT +1FtH Fe<:'r ~ ~,-. ~ - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 reruf. under pr•nalp nr law that mh d«uttxnt and all auarhmrnt. wire <br />- TELEPHONE DATE <br /> prepared uralcr m~ dirrctinn ar wprn i+ion in accordance with a ystem dexiKtrrd <br />-_ - .-1 ~. ~, to u+wre that qualified {w•rvomtel prnperlJ y,~ather and eraluaK the infurmWion - - " <br />- +Uhmhlyd. R[cw•d ~m m) IIIgUIr~' t.f the pl'fKm wr pefwn3 who manage the +}+Iem, , <br />~ _ <br />- <br />` <br />. or th~wr perxxts dirrctlc rrKam+ihk for gatherirtK the Inforttmtiun. the information <br />~ - <br />~ - <br />~ ~ <br />~ ~ j~ <br />~` nwi <br />tru <br />accurate <br />and rnm <br />lete <br />itt <br />t <br />th <br />h <br />t <br />f <br />k <br />d <br />d Mii <br />f <br />h <br />d i~ - ~ <br />' ~- - <br /> , <br />p <br />. <br />ru <br />. <br />o <br />es <br />o <br />n <br />r <br />Ke en <br />e <br />, <br />e, <br />m <br />r <br />e <br />m~ SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 ant aware that there err ciKnificam pa•naLir+ for+uhmiulnlt fala information. <br />i <br />i <br />ti <br />fi <br />d I <br />i <br />f <br />k <br />l OFFICER OR AUTHORIZED AGENT AREE NUMBER YEAR MO DAY <br />TYPED OR P NTED now <br />na+. <br />inchwlinK the pu+s{hllity of <br />ik an <br />mpr <br />++mment <br />or <br />uK . <br />o <br />u <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!! attachments here) <br />w <br />~, -_ _ <br />)O~ S This i. ;1 ~-p;fit t <br />rZ ~ ~ <br />