Laserfiche WebLink
PERMII"rEE NAME/ADDRESS tlndttde Farilur.l'ame/Lxation iJUiJJnentl <br />NAME <br />ADDRESS -~ -~ <br />FaclLm <br />LOCATION <br />rr~ 13i4GP, <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 />Fofm APProved. <br />OMB No. 2040-0004 <br />MI <br />~~ <br />1= <br />5R <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . <br />EX ~ <br />ANALYSIS <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> <br /> SAMPLE <br /> T <br /> MEASUREMEN <br /> PERMIT ' <br /> REQUIREMENT <br /> <br /> SAMPLE <br />T <br />M <br /> MEASURE <br />EN <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> REMENT <br /> MEASU . <br /> <br /> PERMIT <br /> REQWREMENT <br /> <br /> SAMPLE <br /> REMENT <br /> MEASU <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MENT <br />A <br />U <br /> ME <br />RE <br />S <br /> PERMIT <br /> • <br /> REQUIREMENT <br /> SAMPLE <br /> UREMENT <br /> MEAS . <br /> PERMIT - - . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I"'rut-` under psnnlts of law that Chic d~rvna•ut and all atwchments werr TELEPHONE <br />designed <br />with w <br />t <br />d DATE <br />gc <br />em <br />anre <br />preparrd under me direction or supervision in arcur <br />t.. aswre that yualifiad pcrwnnrl prnp•rls gather wad cs rlualt the iaformwti~wt <br />wbmittrd. Bw+ed on m~ inquire nt the per,tNt ur pcrv~a who manage the ss stem. <br />ur those prtsnns dirrctil~ responaihlc for gathering the information, the information i <br />to the beet ~d tm~ knowledge and beikt, true, accuntr, and complete- SIGNATURE OF PRINCIPAL EXECUTIVE <br />wbmitlcd is <br /> , <br />fnrmwtino <br />itti <br />f <br />l <br />i <br />f <br />b AREA <br /> , <br />ng <br />se <br />n <br />or w <br />m <br />a <br />I am aware thwt there are significam penalties OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY 1 <br />TYPED OR PRINTED including the prncibiiih of fine ata! impri,.~nmrnl for knowing sida6on~ <br />h <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments ere) <br />:•( PfdFOIP EV)=1VT I:~ CLAIMI=D. IF CLAYM APPRDV~A I3Y W(~1t;D, <br />~.~uREMErdTS-SEE I. A. 3. PG. 4-5 FDA' -~ <br />- - -.-r,. v l^/1,turZJ1 T0.st_+ 7C.i~TG}3t'-F711(1i.~'f - ~_ t- <br />T1tis~is a4-part form. <br />