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PERMITTEE NAME•~ADDRESS ,IrtiluJ• Fix'rGn .~'umaLcrunrur ifllifferrnt' NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />NAME DISCHARGE MONITORING REPORT (DMR)
<br />ADDRESS - • -.-
<br />I: ~ -^ ~~ ~' `~ ~ ~~5 ~- : _ F --: PERMIT NUMBER DISCHARGE NUMBER
<br />~iGTON ,
<br />FACILITY ~: ~; ;., i 1.~4 MONITORING PERIOD
<br />LOCATION r~f.,l YEAR MO DAY YEAR MO DAY
<br />FROM TO -
<br />Form Approved.
<br />MINOR oMB No. 2oao-oooa
<br />(SUDR 1:~K i
<br />F - FINAL LAM
<br />Rltt`IOFF POMD 7tF'URGATOIRE RIWER
<br />NATE~ Rwari Inctrttr-tinnte hwfnrw rmm~lwtinn this form-
<br />PARAMETER
<br />QUANTITY OR LOADING
<br />QUALITY OR CONCENTRATION NO.
<br />FREDUEN SAMPLE
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<br />EX OF
<br />TYPE
<br /> ANALYSIS
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br /> MEASUREMENT
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<br />NAMErTITLE PRINCIPAL IXECUTIVE OFFICER I cendj under pc~~alt} ai law that this document and all attachments were ,, TELEPHONE DATE
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<br />~ prepared under me dvertiun or supen~ision in aceordancc with a system datigmd
<br />to avsum that yunhticd Ixrsonnrl property gather and evaluate the mfi+rmahon ,~// -
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<br />submitted 13;~ud on my inqutn- of the person or perxxvs who manage the system. A/
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<br />~ • - ( or those persoa4 directh• respunsthlr ti7r gathering the mfonnatinn, the infotmatioo /
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<br />J ~ ~~ ~ ~ ~ }. , ;ubrnnc-,1 h nr the hest of my knowledge and lxheF. true, accurate, and complete.
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<br />SIGNATURE OF PRINCIPAL EX CUTIVE ~ ~ // : ~
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<br />TYPED OR PRINTED un .~~, ..,c ;
<br />at t
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<br />cant pena
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<br />or submitting false m(onnation,
<br />, ~. _c ~i•. p;i.abihh of fine and unpnscmment far Lnuwmg violations. OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />v.+r......... ... ....~ ~... ......,. ..... ... ,~... ....._.-.. ...,..v t. crcr crr..c o.r oaao..nn+m na rec. c/
<br />- ; QD REPORTEC. ClIL. &. GREASI_ -- SEE T. H 1 D, P ° TS5 R•:
<br />- - . ~ ~; ~.:-. !_ I ED FOR '. - 24HR
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