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PERMITTEE NAMEIADDRESS tlndude F'arifitr Name/L~ratiun iJlhJJrrenll NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS •, :: . <br />~yQx .-- PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY ~ Ht3R~21'7~'~ ,I,I i PNI` ~ MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO OAY <br />- A C Q $ 1 ., FROM TO <br />LANCF t1APE, I`tINE t-IAIVAGER <br />Form Approved. <br />OMB No. 2040-0004 <br />r - r s tvML. <br />S:~~°'IIN~ L%RtV <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ' <br /> MEASUREMENTI __ _ <br />~ ~ ' <br />_ <br /> PERMIT :_jn~j <br />. REQUIREMENT :, sf ~~ :~; ,~ ~„ llr' :. ~ -'~~ r°? -~ <br /> SAMPLE ~ ({ Z -_ ' ~ <br /> <br />MEASUREMENT <br />-- : <br />.~ ~ <br /> PERMIT £ s: -.~ n. ' '- , E':'O-+T ii•r~:: t: <br /> REQUIREMENT .:.~Lir•. F1V ~ ~Jt=i'_',_'r" ^'I:~ ''. , . <br /> SAMPLE <br />% <br />~ '' <br />` <br /> MEASUREMENT ~ <br />` <br />' L ~ i <br /> PERMIT ~..~: I~E~C7RT RtP R i <br /> REQUIREMENT • JU~Fa F,VG L-?A i L :' ~`1X ; „: ; ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />AEQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ' <br />NAMElfiTLE PRINCIPAL EXECUTIVE OFFICER I certir> mdrr penalty of low that thi+d«vment and all allwchmenh were <br />ared under mp direction ur supenuion in wcordatcc with a w+tmt de.i <br />re <br />n rf <br />TELEPHONE <br />DATE <br /> p <br />p <br />K <br />to x+sure that yuuliRed perumnrl pruperh gather and esaltrute the Informmion <br />--- ~-- _~ +ahmltled. b1s@d :m ra\ InQUII"{ nr lhl' perwn nr prr+.ml whll manage the ,++-+lem. <br /> ar Ih:ne per+Ull+dlrlYil ~' re~p~mcl Mt' r~~r t;lilhCllnK (he Inhlrnlalll,n, the Inh~rlnallan ~ - <br />- <br />- i ~( +uhmittrd is, to the hN of mr knowledge and Ixlief, tore. xeurate, and complete. " r <br />~ <br />~ ~ ~-~ - <br />. <br />• I am aware lhal them are significant <br />enalties for wbmiuin <br />(ulw inturmatiwr SIGNATURE OF PRINCIPAL EXECUTIVE ' <br />' <br />TYPED OR PRINTED p <br />g <br />. <br />itwluding the p:rsihilits nt tine and imprisonmrm for knowing siolatirHls. OFFICER OR AUTHORIZED AGENT AOOE NUMBER YEAR MO DAY <br />I.UMMtn 1 J ArvU t1CYLAIVA I IIJn Vr AnT VItJLA I IVIYJ tnererence an arracnmenrs Here/ <br />~i9iis is a 4-pan fOfnl• PAGE OF <br />