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PERMITTEE NAMFJADDRESS iLufudr Frtnfin' ~omcN.ni ~uum it fnjlrn m <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 Ap;,roved <br />OMB No 2040-0004 <br />NOTE: Read Instructions before completing this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FReouENCV <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE I ;~ ~~ „-; ' .7.-I <br /> MEASUREMENT ~ <br />~ <br /> PERMIT ? - 'v <br /> REQUIREMENT '''i ' <br /> SAMPLE " r ~ <br /> <br />MEASUREMENT = <br />l . ~ 4'~'• <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE I ~ I ~ - <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />~~ ~~ ~ _ ._ <br />- _; ~ ,_ <br />-' <br /> MEASUREMENT ~- <br /> PERMIT , , E ~' : ~^ <br /> REQUIREMENT + <br /> SAMPLE <br />I <br />L <br />_ ' <br />~ ~ -: <br />' MEASUREMENT _. .__. <br />~ <br /> PERMIT ~ ~ ~ ~-• ' <br /> REQUIREMENT +'' ~ ' <br /> SAMPLE <br />" <br />I <br />~ <br />~ <br />~ i <br />+ _ ''•r' <br />i ~ <br /> MEASUREMENT ; <br />J : <br />.. <br /> PERMIT - » ~ "'~ <br /> REQUIREMENT <br /> SAMPLE • - <br />1 <br />- Y _ <br />1 ^~ / <br />y <br />` ~ <br /> MEASUREMENT _ J <br /> PERMIT ' <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I rertir~ underl„•nulh •.I I:;~ m:rt ih;.d.„umem and nU:dtrehroem~ Hrrr TELEPHONE DATE <br />_ prrpand undrr nq dirv. n~~n ~.r .ulx'r~i.ion iu :rca,rduncc with a ~7 ~trm designed _ <br />- . <br />.'> <br />~_ ,~ -1' r . ;fir <br />-~ T <br />lu trs~nre lhal yu:di0ed yrrsonnrl pnipr rl. g:dhrr aMl eruluu4• IIK infurmminn ~ <br />c~_L---- ' <br />-- <br />~ <br />_ <br />- - + suhmitl.d. Haavl an m} mqu;rs of Uu• I„~rson or pcron. eho muw¢c the craem, t ~ -- <br />~ . <br />~- <br />_ <br />' - <br />i ur thnsr prr.on. dirn'th rr.l„mvMc L.r gethcnng thr inG.rmnfi~m. the mrnrmntion ~ ~ <br />.ubminr+t is <br />t.. fhe tr<•st ~~f m~ t~nuN htdge And IN'IIPI <br />IrIrP <br />:IfCn fJh' <br />:Ind Cnnlldrl[. <br />( ~ L 1~ <br />_ _ ~-- <br />~ I <br />/ <br />_ <br />` <br />• ! . <br />. <br />. <br />. <br />I :m:.....~rr ~lud thcrr ~r..iynificm:i pennlfir- bar •uhmitting falsr informutitm. SIGNATURE OF PRINCIPAL EXECUTIVE { ` <br />TYPED OR PRINTED maudnn;;hc p~.ssihiliq ~~I (inr and impriw~nmrrt Ira Lnoemy siolalinn.. OFFICER OR AUTHORIZED AGENT CR~E NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANAIIUN OF ANY VIVLAIIUN, (FfetBf'CI1Cf an arracnmenrs nereJ <br /> <br />PAGE OF <br />a 4-part forni. <br />