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PERMITTEE NAME/ADDRESS ~Inrlndr I unhn ~:nn, I ;,, ;r:~"n :r Hirt, tar <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDFS) <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-ODD4 <br />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br />OF <br />TYPE <br />EX <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ..- , . <br /> REQUIREMENT - 't i ~ ~ • ~ ' <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 /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I . anJ. "ndrr (N•nulty of law lhxl thi+drN•umem end xll atlxchmrnN wrrr <br />,un•d under mr dirrclion ur wprni.iun in uarordxnrr with a +y+ta•m dr+i¢nad <br />n TELEPHONE DATE <br /> p <br />q <br />to xamre Thal ytwlifiad (N~rwmnd pro(N•rl~ Rxthrr and a•ruluxtr !hr infonnuti.m <br /> .ubmiltrd. Rxcrd Nn m+ inquiry of thr prronn Nr prr+.ma who manx{{r the +.+d'm. <br /> or thn+e penonc dirrcth rrs(xm+iblr for t;alhrrin>; the infornmtion. the inG.rmxdon <br /> +uhmilhd ia. to thr hr+t of m+ know lydkr and helirf, tn1r, aarurxlr. xnd complrlr. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I xln aNYra' !hill IhrrY ire +I~nlfltllxl (N•naI1N'+ for +uhmiuiny fxlw• infNrmutHm. <br /> <br />TYPED OR PRINTED AREA <br />includinc thr (Nnaihilit) ..f Ma• xnd impriwnmenl for knawin>; +iolatiuna. OFFICER OR AUTHORIZED AGENT ODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference an attacnments Here/ <br />FPA Fc _ _r <br />