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PERMITTEE NAME/ADORESS /lnrlade Faciluy ,\'arne/Location ijUtffrrrn» <br />NAME <br />ADDRESS I- ~ = +i_ <br />BOX ~ScB <br />LA CO BI4~4 <br />FACILITY HOR I Z C1N f`1 S t ~;r <br />LOCATION -_ A ~ ~ ~ ~ ,~ ~~ <br />7 :.riVf : ~•' WAi?F . ~t f !\IF MAf~iAf;FR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />r - r a rvfs~ <br />S~L:I`IIfYE L]RFtit~ TO TUTTt_1r C1PcAW <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE I MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE s' <br /> MEASUREMENT <br /> PERMIT - , .,; _~ Fl C ' ~ i^. ~ . - <br /> 'REQUIREMENT ' i13A AVG DRILY M ~ _ , . _ • ..- , <br /> SAMPLE ~ ^' <br /> MEASUREMENT <br /> PERMIT A• 3t ~ a••ii •,i :. }-, C t.,,- ' _. <br /> REQUIREMENT yr=: '. <br /> SAMPLE - <br /> MEASUREMENT <br /> PERMIT sl ,f -r ::r ;~ y. _ : ~ rr ~:, ~ , <br /> REQUIREMENT 'a' ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT az• # ~ 'e ~i't rt, r _ t* I <br />' ~ ,- , <br /> REQUIREMENT :.. Pi :~ <br />1 i+=~ : Ll r.. <br /> SAMPLE " <br />;;•- ; ;_ (.~ MEASUREMENT <br />I r^, PERMIT :.~ -.... - ~ ,. _ ~ . - - <br /> REQUIREMENT - _ Y ,f ,. <br /> SAMPLE <br /> MEASUREMENT <br /> -3 it ~ , `; ~ t ~ ., _ -:: ;- <br /> REQUIREMENT C?F: I L Y M i~ ^~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ -.: ~ ,r ,.. n, r t<. r_ _ ~ . v - <br /> REQUIREMEN7 "..-:; F; ,~~.`C-. ^ %; . I ~; ^ry i MI .. . <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I srrtir~ under penalh ~r law that Ihic d~x~ument and all atwchmrnts wrr: <br />d <br />d <br />di <br />i <br />i <br />i <br />i <br />d <br />ith <br />l <br />d <br />i <br />d ,_,` _ _ <br />~ TELEPHONE DATE <br /> ancr w <br />rs <br />p'tparc <br />un <br />er ml <br />rect <br />on or suprn <br />s <br />~m <br />n accor <br />a .y s <br />rm <br />l;m ~ <br />. - to a+surr 1ho1 yualilled pelvmnel proprrly Kntlxr and e.aluate the information <br />~'- <br />submitted. Rand nn my loyalty of thr perwm or perwne who manugr the +y+tem, ` <br />_ l <br />~ <br />~ <br /> or thosr pennns directh respcrosihle for galhrrint; thr informntion, the information -- <br />~ - , <br />_ <br />' and cnmptetc. <br />submitt d is <br />lu the hest of m. knowledge and belie! <br />tree <br />accurate ii ~~~ I <br />~ , <br />, <br />. <br />, <br />I <br />t <br />itti <br />f <br />ti <br />[h <br />t th <br />i <br />if <br />ltl <br />r <br />b <br />l <br />i <br />f <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ _ <br /> <br />• TYPED OiYPRINTED am awurr <br />ere are s <br />ican <br />m <br />se <br />n <br />orma <br />on. <br />a <br />ggn <br />pena <br />es <br />oc su <br />ng <br />a <br />wdudin thr >,K ihiliq ,d fine and im rrummrm hrt know in riolutions. <br />tl g P ~ R OFFICER OR AUTHORIZED AGENT CR~A NUMBER YEAR MO DAY <br />COMMtN I5 ANU t)<YLAIVA I IVrv Ur Hrv T VIVIH 1 WrvJ (FIC/BBt1Gl' au HiIHGllI11B11lS IiBf"@J <br /> <br />~~~ <br />kic i~ •c'.•}_ri•sn 4'nrni PAGE pF <br />