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PERMITTEE NAMElADDRESS L,~ lode FariGly :Name/lara(ian iflhJJrrrn!/ <br />NAME _ <br />ADDRESS ~ <br />~~~ <br />`A t.~ :~3 <br />FACILITY ;-j[~~{'I ~ ~,~P; ~-j [ ;', L <br />LOCATION ~__ ~ i , Q ~ j <br />zAr~c~ wa~r•: ~i3,v~ t~AfJAGEF <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <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. 2046-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - - ~ ._ ". <br /> REQUIREMENT fnIl~IIMVf•? '''1'"I ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , ~. '~ ' - - ~~ <br /> REQUIREMENT ., ~:;:,,,,,; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ _ ;~ ... x ~ ~ _ . _, , <br /> REQUIREMENT -~ '~r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ u <br /> REQUIREMENT ° V ~' iir ~. i.'_ . <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. -. ~ - _ 1 <br />rc _ REQUIREMENT "~ ... ~ ~ qA I L. ~: i'f'R :,. <br />' SAMPLE <br /> MEASUREMENT <br />- - <br />PERMIT <br />.. .. .. .. <br />:: <br />-.., -,... <br />.. <br />_ <br />_ . . <br /> REQUIREMENT T. i ~ I~i~-~ h ` r" ~ a <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~lr o:._ ,.. .. : ~~: <br /> REQUIREMENT - ' - 13r? t i_'~ ~ , " <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I .cenit. under prmdt~ ..t law maI Ihi. d,avmem and all attachmrne+ were _ TELEPHONE DATE <br /> prepan•d under my direction or w,pen~kian in accordance with a ry+lem dr+igrlyd _ _ _ _,~ _ • <br /> Io u.+sure That yuntified penimm9 prnperi~ gather and ea alualr the in(nrmatiam i <br />~ <br />- -'--' -' _ +ubmilted. Ffa+rd un m~ inquire of the prrwn ur perwn. who manage the .Ltem, f <br />~ <br />~ <br /> or Ihox• pawn+directly r~ pansibk for gathorinK thr {reformation. thn Inrormation ` -" <br />~ <br />c <br />~ , <br /> e and belief <br />acruro le <br />and compkte <br />whmiltrd ix <br />to the hea of mr knowled <br />true l i/ <br />% ~ <br />~' ' j <br />•' <br />~' ' , <br />, <br />. <br />. <br />g <br />, SIGNATURE OF PRINCIPAL EXECUTIVE , <br />- <br />TYPED OR PRINTED 1 am nwarr Ihat there are significam pennllirs for suhmilling lulu inforntafinn. <br />itnludi Ilse slbilih o! fine and im riwnmrnl for knowiu i 1 rtinns. <br />~ r~ ' P x OFFICER OR AUTHORIZED AGENT ARpA NUMBER YEAR MO ' <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!I attachments here) <br />:1PP:.IL~n r_-i?P 'r)YR!?4HR FRFf_':fP ~'1FI~f7 ._ rt=e I A <br />ter„ ~ ~:~_., ~.:; _.,,,.. ~ ~ Thi• is ,+ ~ ,~;rrt ti,rm. PAGE OF <br />