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!nrludr FariUtr .Yamdl.octrtiun if !)ifferrnr <br />NAME '; N FIJ~L_~ <br />ADDRESS `~ I Z ON M I <br />il~~ ?]r~•'_'3 <br />!i ' .1~ <br />FACILITY - I zl~t M I <br />LOCATION <br />r D E31 4~~i <br />1= MAi•.iA:~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 />NOTE: Read Instructions before completing this torm. <br />PARAMETER QUANTITY OR LOADING DUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE 1 <br />~ <br />~ <br />~ ~ <br />f . <br />~ II <br />~ <br />.: fiAEASUREMENT - r <br /> PERMIT ~~, x:: - _ ,_ ._ iV. _ 1~` r~~ <br /> REQUIREMENT ~ , i.7r=~ f'tia '- ~ !- <br /> SAMPLE ~- <br />: MEASUREMENT - ~ ~r <br /> PERMIT ~ sf u tE~•~ x . <br /> REQUIREMENT _~. Dr'"; , ;,_~~ <br /> SAMPLE -~ <br />~ <br /> _ <br />J ~~ <br /> MEASUREMENT <br /> PERMIT -t.- i - .. - <br />~ r <br />_ REQUIREMENT - ' ` ` ' <br /> SAMPLE ;' <br /> <br />MEASUREMENT <br />'~~Z <br />~ q.` ~ <br />. .-~ PERMIT ~. ~ :r _ ..: . <br /> REDUIREMENT r; r~,`:~~~~ ~k ; i. <br /> <br />SAMPLE <br />~ _ <br />-I , <br /> <br />! <br /> MEASUREMENT '"~%~~~~ -s•'`-'-'- ~ /~ <br />[t- <br /> PERMIT t ,t ., ~ ,.. ,r _ y. -. - <br />" <br />' - __ <br />- REQUIREMENT _ . ' i ~ H4G iyf? <br />R ~ ~Nt? <br />i <br /> SAMPLE <br />~ 2 <br />~ <br />~ ~ _ <br /> MEASUREMENT ~ ° ~' ! ~~' <br /> PERMIT ., <, , . ,.. .- ..- , . , . , _ - . <br /> .REQUIREMENT ": 'r' ~ _ f Tf2 f•' ~ ~' <br /> <br />SAMPLE <br /> <br />l`-~ ....z- ... --. <br /> <br />' <br /> <br />i <br /> <br />' <br /> MEASUREMENT -' ~ <br />PERMIT r. ; c ~ .. ,. - ., .-~ <br />REDUIREMENT ~ `-~-r M ~ ): - <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ~+•nu+ under prnulN of laa Ihat thi+document and all attachmenU were TELEPHONE DATE <br />prepurrd under tm directl[m or wprni+inn iu accordance w ith a s)aiem designed <br />Ia o_+~ura Ihut ywlffird prnonncl prnpert~ Rather and evaluate thr information - - ~": <br />- __ _ ~ _ ___ _ _ __ submhird. Buxd [m m} inyuin or the prrvm ar prr+un+ who managr the +pvtem, 1 <br />i • <br />\ <br />I ~ <br />I - - ~ - or tbnse petwro dirMh m{a~n+ihlc for yuthrriny the udormatiun. the information <br />- ~, _ <br />d t <br />d <br />l <br />t <br />' <br />~ ~~~ ~ _ <br />, <br />comp <br />mlirf, tn,c, anvrate, an <br />e <br />/ +ubmiurd i+. to the hevt of m. knowtrdgr ,m <br />e. SIGNATURE OF PRINCIPAL EXECUTIVE <br />~ <br />[ <br /> <br />• I am aware that thrrr an significant penalUe+rw wbmittin¢ false information. <br />t f <br />ti <br />tf <br />i <br />i <br />f fl <br />d i <br />i <br />w <br />i <br />l OFFlCER OR AUTHORIZED AGENT AREA NUMBER YEAR MD DAY <br />TYPED OFf PRINTED nuw <br />nK <br />u <br />.ms. <br />iceluding tlse p[n+ <br />hil <br />ty o <br />oe an <br />mpr <br />sonmen <br />or <br />o DE <br />COMMENTS AND EXPLANATION OF ANY VwLAI IVrvs (rrererence au anacnmenrs nere~ <br />-~ F <br />G~,:. ~ .-. - _ <br /> <br />