Laserfiche WebLink
'-i_~+:4iiTEENAME/ADDRESS.!.: ~, i <br />NAIVtE <br />ADDRESS " <br />- • ~, _ <br />,. C3 t+ ± t <br />FACILITY ~L[~ , _ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Forrn Approved. <br />OMB No. 2040-0004 <br />DISCHARGE MONITORING REPORT (DMR) <br />;~ L: <br />PERMIT NUMBER DISCHARGE NUMBER F I t~iF3L RIIL/;N <br />MONITORING PERIOD SEI7I F'Of~T} TO FiF_D WASH <br />YEAR MO DAY YEAR MO DAY <br />FROM TO X ' <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREDUENCY <br />OF SAMPLE <br /> EX SIS TYPE <br /> ANALY <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> ' ' ' , ~ .. ; :: ~ F~ .:, <br /> PERMIT -- <br />~ ~ .. t ~C'T~!'•r <br />;= ~ ~ L-: ~: , , REQUIREMENT <br />'..- - SAMPLE • <br />IJBP = ; _ <br />'? MEASUREMENT <br />, <br />:; c;' PERMIT ' _, .,~ .L ~ :: ~ . <br />" • ~. i~ • , <br /> <br />F"t } L.i.ii 1; <br />REQUIREMENT ii <br />f <br />-~`•..` SAMPLE <br /> MEASUREMENT <br /> PERMIT , . rt <br />~., , . .: „ . _, <br />- t, .. r. ~ <br />+"~."~'•l~h~i . ~, ~ ~ . <br />~~ REQUIREMENT <br />. ~ SAMPLE <br /> MEASUREMENT <br />r <br />' <br />' PERMIT i -~ .; <br />~ ~ _ r <br />;'if_1^ITi `. i <br />r=r i- <br />. ~ REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> - t ' r~L~ <br /> PERMIT ~ :... , . <br />,- <br />~1' ~ ~, REQUIREMENT (~+` <br />-...i~' SAMPLE ~' ' <br />j'F{RU MEASUREMENT <br />- PERMIT , .. ., - . _ r ~ ..: ~ r+.'', <br /> <br />~- rr ~ <br />REQUIREMENT <br />- ' ~~ I ~ <br /> SAMPLE <br /> MEASUREMENT <br />_ PERMIT <br />• <br />. REQUIREMENT ~ + <br />AME/TITLE PRINCIPAL EXECUTIVE OFFICER I certil} under penalty of law that this document and all aunchments were TELEPHONE DATE <br />N ared under my dirccuon ur supervtsi.m m accordance with a system designed <br />re <br />l~ ~ r ~ [ <br />~ ~ ' p <br />p <br />to nsstue that yualified personnel properly gather and evaluntc the informaticx, <br />ersnns who manage the sysrem <br />i <br />rson or <br />d <br />i <br />f th <br />b <br />i <br />B <br />i ' ~ <br />>~ - <br /> . <br />e pe <br />p <br />ase <br />on my <br />nqu <br />ry o <br />su <br />m <br />tteJ. <br />tfie infnnna[i[m <br />the in(ortnation <br />' <br />nstble for <br />atherin <br />d <br />l <br />h ~~` <br />_ <br />'~" ~~ ~ ~'- ' '' ~' - - <br /> . <br />y re, <br />po <br />g <br />g <br />to [ <br />ost pcnons <br />rrrct <br />l <br />d '` ~' <br />- - <br />~ ete. <br />comp <br />submitted t5, to the best of my knowledge and bcLcf. true, accurate. an SIGNATURE OF PRINCIPAL EXECUTIVE % - < < <br />• 1 um aware that there aro significant penalties for submitting false infnmwtion. OFFICER OR AUTHORIZED AGENT AREA <br /> w <br />l <br />tio <br />s <br />t f <br />k <br />.i <br />f f <br />i CODE NUMBER YEAR MO DAY <br />TYPEb OR PRINTED n <br />. <br />sonmen <br />or <br />nu <br />mg <br />o <br />a <br />including the passibility o <br />ine and impr <br />COMMtrvIJ ArvIJ cwrv+rrrsr[vr~ yr .,r.. .~.,w.~,.....~.., t. ~, ~. ~....~ ........................ ..... _. <br />'.'h <br />EPA Form 3326-t (Rev. 3/99) Previous editions may tye used. <br />IP. EVENT - SEE I. A. 1 ~ PG. 3. FOR RE(3Ul <br />VG It~lSTF~UCTIRNS - I.C. 7.. PG. 14. <br />r;,>cE o= <br />7lli: l~ a ~-nz+rt I~~rm. <br />