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PERMITTEE NAMElADDRESS (Include Farifity.4amr/lncatinn iJ/hJJrrent <br />NAME <br />ADDRESS '~' '- <br />FACILITY j~~ _ 'r_;"tjy f•? 1 j~': <br />LOCATION ~ _ <br />.. ~ ~. ,-- . ~ ., T.:- t., , w 1 r. n:.: n <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <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 2040-0004 <br />E OFiNG TRIII TO Tt;TTL.E L <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. <br /> <br />EX FREO~ NCY <br /> <br />ANALYSIS SAMPLE <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />• - r <br />: ~ ~ _. <br /> PERMIT <br />REQUIREMENT .; .~ ~ .. <br />_ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />SAMPLE .. , -.:~ : ;~ <br />~ t <br />`i ~- <br /> MEASUREMENT <br /> - z ... <br /> PERMIT -~~ 1 <br />: .REQUIREMENT i.''J5T I~IrI:' <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMCf <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMR <br />REQUIREMENT <br />NAMEffITLE PRINCIPAL EXECUTIVE OFFICER I Trtfry under prnmry allow that ihi, diKnmrnl and all altachmrnts were TELEPHONE <br />pnpured under m~ dirrelion or wprn{,fon in accurAmne with ~ ,7sten deigned _ y <br />to a~ urr that qualified prr,onnd pruprrl> gather and evahwtr lhr infnrmalion ' <br />. _ _ w ___ _ ,ubmittcd. Hard un m~ inyuin ut the prr,iat or per,on, who manage the v„Irnt. i ~ <br />-. nr thux~ pcrsun.+ dirrrtlv respm,ible for l;athcring the ioformutfnn. the in[ormatian ~' ~--- ,, <br />u whmilled i., U. Ihr best ~~ m) knowledge and brlkf, lrvr. acruralr. and cam r. ' r - ~ t <br />~ SIGNATURE OF PRINCIPAL EXECUTIVE ~ / <br />' <br />i <br />i ~ DATE <br /> <br /> <br /> <br />, _ , I ~ .~ <br />r <br />. ; .11 <br />41 <br />~ ~ <br />1 I um aware that thrro are+ignifnam penalties twr vnMniuing talvc fntarntad~m. OFFICER OR AUTHORIZED AGENT ARpA NUMBER YEAR MQ DAY <br />TYPED OR PRINTED including the pmsihilih id lino amt impriwnment far km~w ing +iolatinns. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) ~ ~ ~ t„I I T ~ <br />I = ~ r ~,~,~ _~ _0-t (Rev. 3/99) Pre~~ecs :.~, <br />04~~r ~ T)ti <br />