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PERMITTEE NAME/ADDRESS Nnr6tdr F'aciL'!f .\'antdloratinn iJIhJJnen4 <br />NAME <br />ADDRESS <br />FACILITY , <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDESJ <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br /> <br />OF <br />SAMPLE <br /> EX Y <br />IS TYPE <br /> ANAL <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT • <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT . h• .- <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT ,. - ,_ <br />.REQUIREMENT ' <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certifs under prnulh of law shot Chic d~xument and all anochments weer TELEPHONE DATE <br />prrpand under me direction nr suq~nicion in wcortluncr with a crstem drsi¢ned <br />to aswre that qualified prnnnnel prnperk gather and r~aluntr for {nfortnation <br />cuhmined. Based nn m~ inyuin of the person ur prnnnc who manage the saem. <br />or thrtx• persons directh resp•msiblr for gnthrring the informotion, the inG•rmn0on <br />submitted is, to the test of m~ knowledge and helief. true, anvratr, and crxnplete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> 1 am Dwarf thm there are cigni6cant penaltise fur wbmitting faLcr information. AREA <br />TYPED OR PRINTED inrhaiing tnr poscihilitr n! fine and impriwnmem for knowing siolatlotts. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attacnmenrs nereJ <br />EPA Fp~CI ':2U-1 Hev :i ~:~, P!av~OU~ ~'-i '.'~r. _. ., .-- ._ ~ I Ilia i~ :1 ~=-{~:!fl ItN-I11. <br />