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PERMI7TEE NAME/ADDRESS ilndude FariGrj :Yanerllaotiun if llijjrrmtt NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />NAME - DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS ~ _, ::. ti (Jf•t t`i l i`~E <br />BGIX C?c~ PERMIT NUMBER DISCNARGENUMBER <br />-~ MONITORING PERIOD <br />FACILITY HER J LON rl .j ; YEAR MO DAY YEAR MO DAY <br />LOCATION h't FROM TO <br />Form Approved. <br />DMB No. 2040-0004 <br />°<h1I N?= I7RNG T4 TUTTL B <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />OF SAMPLE <br /> EX LY TYPE <br /> ANA <br />SIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />- SAMPLE <br /> MEASUREMENT <br /> PERMIT "#-r ^ a ;t ,' ' n ~ RT ~rPOR'1 Jfd`..' ~r <br /> REQUIREMENT , ::- 'v "'I X Mf :'•J T~• <br /> SAMPLE <br />" MEASUREMENT <br /> PERMIT ?r.;,. r _ „ . , . ~j ~> : ,_ <br /> REQUIREMENT =,VG _. '" ~'• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ - ~.i•,ik ~ ... : ~ T r 1' _ <br /> REQUIREMENT • ; r'; V.;; P1 h ~ 1: ~ ~ _ <br /> SAMPLE ~ ~ ~ ~" - <br />c <br />LY DI''-,':_ ~ <br />,•d7 ~r;l MEASUREMENT <br />_ <br />_ <br />~~, - PERMIT .. ~~ ~ ~-., - - ;t-~ :i .. }- , ~; . . <br />_ - . REQUIREMENT - ) ur~: <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ~ <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER 1 arrtif} under prnulh of law that This d~wurtn•nt and ull amichmrnn were <br />ared under nn direction or suprnisinn in :rca,rdunce w ith a system drslKncd <br />re TELEPHONE DATE <br />__ _,_ - p <br />p <br />to anwe that yuali6,d prrwnnri pny,rrly Kathrr and e+aluutr the information - - -~-'- <br /> <br />-- ~ +uhmittrd. ffasrd on m+ inyuin ~d the Iw•r.,m or prn.m+ w bo manage the r•~stem, <br />or thou prnon+direcdy rr+lwmsihlc for ytxlbrrint; the information, the infnrntalion <br />~ <br />G f <br />~, <br /> t <br />t <br />c <br />r te <br />d <br />o <br />l <br />t <br />d <br />I <br />d <br />k <br />d <br />d b <br />li <br />f <br /> nuw <br />t;e an <br />, <br />rue. oc <br />u <br />, an <br />c <br />mp <br />e <br />e. <br />suhmittr <br />iti to the <br />x+t ~ <br />my <br />e <br />e <br />e SIGNATURE OF PRINCIPAL EXECUTIVE - <br /> 1 am aware that Ibere are +iKnificam Irrnultte+ for .ubmittint; fatae information. AREA <br />TYPED OR PRINTED irKludinR the pasibility of firer and impriwnmrnt fur knowing+iolatinn+. OFFICER OR AUTHORIZED AGENT C D NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION Ur ANY vwLa t wn-s frrererence au arracnmenrs nere/ <br /> <br />