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PERMI7TEE NAMElADDRESS ilncludr F'a~i4fr ~'~'amr/Lrxahon iJIhlJere~l <br />NAME Uf ~ • l._ t_ <br />ADDRESS • <br />~ ~L' <br />' _:'~ 3144 <br />FACILIrv i iC+R I ZLJ-'•~ ^; ; r ; <br />LOCATION ~_A~y,_I L. `_ $1~G4 <br />Ahtt!`t' t.tnrtr. ..~Tht1= M,]K4Gr=Fi7 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 204D•0004 <br />~ TUTT? F <br />,'- <br />NOTE: Read Instructions before completing this form. <br />r. ~ <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION r1O, FREQUENCY <br />OF SAMPLE <br /> EX AL <br />S <br />S TYPE <br /> AN <br />Y <br />I <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br />' PERMIT <br />REQUIREMENT ~~ <br />„I I N I i`l~t'r <br />' `." <br /> SAMPLE <br /> MEASUREMENT <br /> - <br />• PERMIT r -a - :~ ; _; r .. <br />{' <br />: <br /> REQUIREMENT + + Av;, _ + <br />,. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , .. ,... :r ~ .~ - • . r <br />, <br />; <br />f ,.. <br /> REQUIREMENT "..: <br />~:; i ;, ;~ . <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ - T.::- ~ <br />... <br />';r''. _r~.Y T'17. ; <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT r l.; . - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> i .. -. .... , . - -.... _ - <br /> PERMIT r _.. <br />• <br />~ ~ .. <br /> REQUIREMENT 'rt I i_ <br />° <br />. <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I rrrtif~ under prn:Jq ollew mm thin du<-~ma•m and ai! ouaahm.•nt. were TELEPHONE DATE <br /> prepared under nq dimti+m ur wpenision in arrunluncr with u sistem dc.iRned - _! <br /> N unsure thnt ytwlifird persc+nMl prnpcrl~ ynther and r.uluate thr informatkro .. <br />- - ' ~- -- ~ _ whmittrd. Raaed rm m~ inyuln of thr pcrM+u ar per~nns wbu mana>Cr the .y.trm. <br />rnnm dirertl~ re+p+nsihk G,r guUu•rfnq the inrormatl<m, the infonnnti+u+ <br />or thow~ 1 ~ ~ <br />~' ~ `'• <br />s t <br />. <br />- ~ <br />'! ~ <br />/ <br /> <br />~ A <br />' ."J <br />~~ <br /> p <br />t <br />d <br />l _ , <br />~ ; <br />~ '( <br />~ <br />- _ <br />I <br />', <br />~ <br />~ <br />~/l <br />\ <br />~ cump <br />r. <br />r <br />+ubmittrd is, to tlx• Ixst of m. knox hdlta• and I+rlirf. wr, arcurrte, an SIGNATURE OF PRINCIPAL EXECUTIVE <br />I ` <br />I _ <br />: <br />( <br />y <br />~ I am aware that then art signifiavnt penalties for .abmitting false information, RIZED AGENT <br />A AREA <br />TYPED OR PRINTED ineludin¢ thr p+ssibilin of fine and imprixmmrnt for knnxing sinla6+ms. OFFICER OR <br />UTHO NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION Ut ArvY VIVLAI larva Int:rrrt:ncc m+ nuaw+n+cnw ,+c, c~ <br />This <br />