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PERMITTEE NAMEJADDRESS ilnrlude Fociliry:Vamr/lamration i/[hJjirenU NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FAC1urY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />',NCB, i~JADI_. <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 />' <br /> MEASUREMENT ' " <br /> PERMIT <br /> REQUIREMENT ~ ' <br /> SAMPLE <br />: <br /> ~ <br />~ <br /> MEASUREMENT <br /> PERMIT -~ ~ T- i. ?: -: i • <br /> REQUIREMENT -"~ " <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT -% ~ ~'~~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ". ;" . <br /> REQUIREMENT <br /> SAMPLE <br />~ <br /> MEASUREMENT - <br /> PERMIT ' <br />- <br /> REOUIREMEN7 - '- ,;, = I- ,` <br /> SAMPLE ` <br /> MEASUREMENT / <br /> PERMIT ,: .. <br /> REQUIREMENT ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - . ~ :. . <br /> REQUIREMENT '~ '~ `- r` ~ ~ `~ <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I mrtih ender p•nalry of iax Ihat this dormtxnt and ull attachments were <br />d <br />d <br />i <br />d TELEPHONE DATE <br /> prepared under m) Jirrction nr +uprnisitm in anur <br />ance xith a y+tem <br />m <br />gne - <br /> to a>snrr that gtmlified per.enmai proprri~ gather and e+alualr Iltr information <br />_ wbmhtad. Ruud rm m~ inyuir. of Ihr prr,on or prrwaa xho mamgr ttx +~arm. <br /> or those persons diredh responrifde for gathering the information. the inforntation l <br /> knnxled <br />e and belkl <br />+acw:ue <br />and ewnplete <br />wbmittrd is <br />to the hest td m <br />True - ' <br />_ _ <br />~ , <br />y <br />g <br />. <br />. <br />. <br />i <br />f <br />I <br />f <br />U SIGNATURE OF PRINCIPAL EXECUTIVE ~ ~ - <br />TYPED OR PRINTED I ant aware that thcrt arc significant penalties for wbmltt <br />ng <br />alu <br />orma <br />Oa• <br />n <br />including the pmsihilitr of fine and imprionmrnt for knoxFng siolathat+. OFFICER OR AUTHORIZED AGENT ARSE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLA7IUNS (Hererence al- anacnmen[s nere~ <br />EPA Fcr•~ 3320.1 ~Re', 39_; Pre:~:a~,e. c~„ _ .. -, •I~~li~ 1< a -3-p:Ul itll"ill. NAGE of <br />