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PERMITTEE NAME/ADDRESS .lnrludr /ani,n \wnr7~~rula~r. ;! NiN.rrnr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDE$J <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />pr^•. ApGroved. <br />FMB No 20x0-0004 <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 /> MEASUREMENT ~~~ <br /> PERMIT ., ~: < r ~ ~• _._ - ~ .. ... :. <br /> REQUIREMENT r~r,l `, - 'r <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 /> 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 I .rrw. uodrr {Ilrnulq of law lhut Wi+davnu•nl wld all allaehmrnt+ uerr <br />re <br />arrd undrr m <br />dirrathro ur .u <br />er+ision in u <br />cnrJ:mrr wi81 a +rsta•m da•.i <br />nrd TELEPHONE DATE <br /> p <br />~ <br />p <br />p <br />c <br />tt <br /> In LL+nl'a• IhlII y11Jl1fitd {tet'wnlna'I prllpl'flY t;ut hrr anJ r+aluutr the infurmnlinn <br />-- - - -. whmined. kiu+ed ,al nl. inyuir. of the prrwn ur pcrwn+ ++hu manor;r the +psmm. <br />' ar Ihlwc pa•nom dinv~d+ rr+Ittln+iMe fur katlu•ril~ Ihr information. the information _ - - <br />• ~ <br />' .uhmittnl i.. In thr hr+t o7 m) knuwlydKr and hrlicf. Irur, ncouulc. and cum plrte. `~ - - <br />• <br />- 1 am <br />~arr Ilud Uu•rr an• +i <br />n ifn•am <br />l•nnltic+ for .uhmiltin <br />fal+e inform <br />tio SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED g <br />u <br />p <br />K <br />a <br />n. <br />mchnlin the d Ifit. „f fine and im Iri+oomrm for Lou+a in i i tion.. <br />+' P"" ' r ~• na OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!I attachments here) <br /> <br />-i~hl~ I~ ;t ~+-4117 I~ilf'lll PAGE OF <br />