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PERMITTEE NAME/ADDRESS Inr(:,d~ Fnt,liq ~u,m i, .:,: "::: t„I/,,.,u r,nrior~n~ Po~~uTnr~r oiscHn~+ce Eun~iNnnor+ SrsT=_rn ((NPDESJ <br />NAME DISCHARGE MONITORING REPORT (DMRJ <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />~^ <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION tJ0- FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ~ _ ~ <br />~ "' - ~ ' i i ;~.t ~ , T ~! <br /> MEASUREMENT ~ <br /> PERMIT •: ~ +., <br /> REQUIREMENT ' <br /> SAMPLE _, ~_ <br />- <br />~ ~ / . <br />~ t . <br />' ~ _ <br />( j1A ~ <br /> MEASUREMENT <br /> PERMIT _~ - ~ - <br /> REQUIREMENT ~ " <br /> SAMPLE I ~ ~ ,~ - i - - L ~i a <br /> MEASUREMENT <br /> PERMIT ~ -:.: ; <br /> REQUIREMENT ~''~ ~ - =- <br /> SAMPLE c-- r- '~ ~ I: ~ 1 i-, <br /> MEASUREMENT ~ '-" '" <br /> PERMIT ~; r• . _ r • ~ .. .- . <br /> REQUIREMENT <br /> SAMPLE ~~. T ~ <br />~ , <br />~ <br />~{ <br /> MEASUREMENT , ~- _ . ; <br /> PERMIT .--,~;L;r. .il. i_:r -: .. - -' . <br />- <br /> REQUIREMENT -; A ; ~,. - (i-i <br /> SAMPLE ~ <br />L I '' <br />-' ~-_ <br />`- ~'! ~~=1 IrJST.~~ <br /> MEASUREMENT - <br /> PERMIT t'.. - . , '- x'yr, " <: - ~ ~-~~ <br /> REQUIREMENT - <br /> SAMPLE <br />"" QS ~ ~ .~ ~~ { Sva <br /> MEASUREMENT <br /> PERMIT ...- . 4 .. .. .- , .~.. . <br /> REQUIREMENT ~ ' <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER {certit) underprmdq uttu..lhallhl+dlNllmenl~ndaltHtWfhment+NPCC ~~ % TELEPHONE DATE <br /> <br />~ prepartvl uttdrr m. direction ar ruprni+ion in wcw,rdarnr with u +)+trm de+i>atrd ~:_ "_ <br />~ <br /> t.. a++urr that yuuli0nl prr+nnncl pn~•r{a Kather and evuluntr the mtormatiun ~ 1 <br />~ <br />~ <br />1 y ~-- •uhminrd. Ba+ed un my toquin of the prr+.~n ,~r {w•rwm who m~naRr the +~arm. .^ - ~_~ <br />~. <br />~~ ~ <br /> or th,r.' {x•nnns dtrtYd~ rr+ponable for µlhcrin>; the information. Ihr information ~- ~ <-sue -~ <br />• _ <br />' ` <br />~ <br />~'- d a+ <br />In th <br />.t nt n <br />~ Anow led <br />e and In~lKd <br />true <br />accurate <br />and com <br />lete <br />+ <br />h <br />itt <br />h ~•t • <br />' <br />` <br />J~ , ( ~~~ <br />~ <br />~ <br />_ ` <br />y ~ ~ q <br />g <br />, <br />. <br />, <br />p <br />. <br />u <br />m <br />. <br />. <br />e <br />r SIGNATURE OF PRINCIPAL EXECUTIVE " '" <br />+ '" `~ <br /> <br />TYPED OR PRINTED I am aware that there un' .igndicrnt prtml(Fe+ for wbmituuR fal+r inrurmalion, <br />ineludinl; Iha {nn+ihilit..d Rnr uad impri+wttmem !or -nowinQ .iola4wn+. <br />OFFICER OR AUTHORIZED AGENT AREA <br />D NUMBER <br />YEAR <br />MQ <br />DAY <br />COMMtnt, Anu t~rLwrvHllvrv yr HIVT VIVLNIIVIVI tnrrerencr do auacnalenls nrrr~ <br />hi- <br />