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PERMITTEE NAME/ADDRESS t/nrlade f'arilih.~amdlururinn iJlHJfrrrnN NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />NAME : DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS ~ • <br />LD X PERMIT NUMBER DISCHARGE NUMBER <br />`"A ~ MONITORING PERIOD <br />FACILfTY Hn:`~ I Z U 14 i'i 1 f'; t:. <br />LOCATION YEAR MO DAY YEAR MO DAY <br />_ A C U FROM TO <br />i_ APdC E WriDE, i'1 I NE MANAG. <br />Form Approved. <br />oMe No. 2oaaooal <br />5R~<f9If~lE LRNG TRIB TC <br />/ ,. <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> i AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE i .. _ .- :. i - <br /> MEASUREMENT <br /> PERMIT .. - .- -~ _ i'ORT F !.v. -. ~ .. <br /> REQUIREMENT •• a AVG LA I L-f i'~ X ' ! ~ % :_ rr f •_,! r <br /> SAMPLE ~_ , <br /> MEASUREMENT <br /> PERMIT ,- ° _ r' i~ i r 1 <br /> REQUIREMENT -iVG DH I ~.Y `i ` <br /> SAMPLE ' ' <br /> MEASUREMENT <br /> PERMIT .. ~`~-~ :: fi~•::.;. ._ ,~ , <br /> REQUIREMENT ~ "`r~ Ati`G. - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT = ~ c: if - r ~.. I T.. ..?; • ~ . ._s;~ ; i_.;-; ,..;_: <br /> .REQUIREMENT ":3 ur=~ It .`~ .Ll.,. .- ; ~ t <br /> SAMPLE • <br /> MEASUREMENT <br /> PERMIT i_ ~t ---Y _: ~_ , -- -.. <br /> REQUIREMENT `''• <br /> SAMPLE <br />- _:~~. MEASUREMENT <br /> PERMIT ~- ~ t}-it ~ ~ d t ;=-if t- _ •. .. .. .._ ~ ., <br /> .REQUIREMENT •'ir, :j`.'' <br /> SAMPLE ' <br /> MEASUREMENT <br /> PERMIT r• a : • .F : _ .. n _ _ ~ a _ •- <br /> REQUIREMENT I =tC113fi F,`. %;. ? i -t i '_ '.i ;.~ ;: , , ' <br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I certif. under penalq of inw mat mh document and all mtachment+were <br />re <br />ared ondrr m <br />dirretion or+u <br />rni+itm in accordanrr with a <br />+tem drti <br />tud <br />/ TELEPHONE DATE <br /> p <br />p <br />} <br />p <br />y <br />g v <br />_--~ <br />_ Iv n+urr that yualiried penonnrl prnperl~ Kathrr and c.aluate Ihr infurmutitm ) I <br />/ <br />~ <br />~_ _ sabmiued. Based tw m! inyuin~ of qte prr.un ur penom who manaRr the +)'strm. <br /> <br />ur thux• per+oo+dirrc~tl~ re+pwtible for eutherinu the information. the inrornwtion : <br />` . <br />- 1 <br />_ <br /> <br />~ <br /> <br />- <br />-t ~ I <br />J I ,t jl \ ~ <br />'_ i suMuitt d is. to the hest of nn kra,wlcdtte and belief. true. accurate. and complete. . <.) ~ ~ J(; ~ ~ .,~ c-t ,~+ <br />~ <br />- <br />- I am aware that there arc +i <br />nirxant <br />enaltk. fur whmitlin <br />ful.e infurmathar SIGNATURE OF PRINCIPAL EXECUTIVE - • _- <br /> <br />TYPED OR PRINTED g <br />p <br />g <br />. <br />itxludin the uhiliq of fox and im n unmcot fur Lnnwin riulatiom. <br />~ a~ ~ p + e OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />GUMMtN I J AIVU tAYLHIVH I IVI`I yr HI`I T V IVLH I IIJIVJ Inererence nn bancnmenrs Here/ <br /> <br />