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~~ <br />PERMITTEE NAMElADDRESS Inrludr FruiGn :~'amr!lnrluinn iJlliffrrrnU <br />NAME - "'SIN <br />ADDRESS <br />;_ -_TE <br />.:CJCD n gr <br />FACILITY - syE <br />LOCATION -1~ r; [t f~~ <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 Approvod <br />oti+g No 2oaaoooa <br />(SI <br />,: <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY SAMPLE <br />OF <br />ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT - ~ tiu ~) ~ ~I I j~~1 L <br /> - ' <br />' <br />T ~' <br /> <br />PERMIT <br />REQUIREMENT <br />~ _~ . <br />s 'e .. <br />- <br />• <br />.. <br />- <br />P1! ~N i I ; - ' <br />- <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />' <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER { crrtitl under penalh of iuw That Ihi, Ancumcm and all attachment. wen <br />prrp-rnd under m~ dircin~ n or wpcn isiun in anordan.r with a +~ctam decigltrd I~ <br />-.----~- I ~ <br />~ - TELEPHONE DATE <br />- _ - <br />. - .- - ~ - ~, ~"- <br />` to n cur • that yuulifird {w~r,~WU~ properly Kalher ottd r~alualr the in(~umnlinn <br />,uhmiUnl. Bated un m~ myuin of the prrcon nr pervmc whu manage the cy,tem. <br />/Milhte rnr gallMfing the Int(IrnLIl111n. the intnrmallOn <br />tf~ ra^ <br />di <br />tl cu <br />- y <br />1 <br />~_~~ _` ~ -~ <br /> <br />l <br />--~ <br />`f <br />3 <br /> <br />/' ( <br /> <br />7 <br /> <br />~ ~ <br /> <br /> <br />~~ p <br />lnst pen n. <br />nr <br />i~r <br />wbtnhtrf ~ t Wr tea ~~t np Anue1/vl{;r end Arlie(.Intr. accurate. and c~mtpktr. <br /> <br />$IGNATURE OF PRINCIPAL EXECUTIVE ~ J <br />~ V <br />~ l <br />~- ( <br />C~ .. <br />-` / <br />`j/1 ~ <br />L• <br />' <br />J ; C-v <br />r ;;~~~ I am ueare that Ihrn~ .u~~ ~ignificam prnultiec fnr ,uhmitting fakir mfnrmatimt. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />TYPED OR PRINTED including the p....ibiliq ..f ftnt and imprisunmrnt for knowing.ioWtium. CO <br />COMMENTS AND EXPLANATION OF ANY VIOLAIIUIVS (r~e-erence an ar[acnrnenls /IC/C~ - <br />=R PRT?!'IK' Ev>:n - SEE i. F ~. PG. 4 FDR R1wQUIi"tEI•tEN~~u. <br />Ttus'is a 4-part f~nn. PAGE OF <br />_ -,,, <br />