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PERMITTEE NAME/ADDRESS tlnrludr ForiGtr .~amr/!oration if Ihffrrrm <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 /> T <br /> PERMI <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under prnalt) of Ixw that tttic documrnl and all xttachmenLc were TELEPHONE DATE <br /> preparrd under me direction ur wprnicion in accordance Kith a srdrm decit~ed <br /> In acwre that yuulifkd prrv~ntxd pntprrl~ Cathrr and r~ xluxta• thr information <br /> .uhmFll d. Rtnrd tm m~~ inquiry of the prrsnn ur perwn~ who mxnxtte thr .)qem. <br /> nr thtnr per.onc dirrcU7 mpmcihk fur ¢athcrinµ thr information. the infurmaliwt <br /> cubrniued fc, to thr heel of my knuwled>tr and hrlief. true, acwrate. and complrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> l am aware that there are ciltrtirwvnl penxltica fur whmitting false iufortrutioe. <br />t f <br />~iol <br />ti <br />li <br />f f <br />d <br />k <br />k <br />i <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED wr <br />nnw <br />a <br />om. <br />including thr pKCihi <br />t... <br />ine an <br />impr <br /><xtmeo <br />n¢ <br />COMMENTS AND EXPLANATION OF ANY vIULA 1IONS (Hererence a-! anacnmenrs nere/ <br />EP1 r- vrm 33201 IRav ~'9L 1 F'!P'/:6U~ =,1 t.~,,~ r. ~.; he i._;,., I ~'. i ~ I ~ ;t -1-i~:1~ f i ~ "l I <br />