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PERMITTEE NAME/ADDRESS tlnrlude Fari6lr .Yandlxation iJ t>iJJerrntl <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />;.: ~ ~ i <br />nt1,.- ~. <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 <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX ANALYSIS TYPE <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT . <br /> REQUIREMENT ~ ' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> - <br /> PERMIT '` " <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> T <br /> REQUIREMEN <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ _ _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMIJTITLE PRINCIPAL EXECUTIVE OFFICER I crrtih under ps•nalh of law that this dmrmenl atd u11 atWchmrnb were TELEPHONE DATE <br /> prepared umler my dirrdion nr wpenislon in ocrnrdanre with a system desirJxd <br /> to a+sure that qualified prnonrrei properly gather and esaluate the inrormatlun <br /> submitted. Rnsrd nn my inquin ~d tlu pers.m nr prisons who manage the c~stem. <br />- nr thnsr person. directly reyxmsifde for gathering the Inrormation, the information <br /> <br />t <br />d <br />l _ <br />~ <br /> amrp <br />r <br />r. <br />submitted is, la the bc+t or my Annwlerlge aml 6rllef, true, accurate. an SIGNATURE OF PRINCIPAL EXECUTIVE ~ ' <br /> 1 am aware that there arc cignifcant penaltic roe wbmitting false information. AREA <br /> owi <br />sinlatirms <br />t for k <br />hill <br />f l <br />d i <br />i OFFICER OR AUTHORIZED AGENT DE NUMBER YEAR MQ DAY <br />TYPED OR PRINTED . <br />mpr <br />sonmen <br />n <br />ng <br />including the lxnsi <br />n o <br />iar an <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />