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Form Apptatetr. <br />hJAiICNAL POLLUTANT DISCHARGE ELIMIPlATIOC! SYSTEM (w~D~~J OM6 N0. ~TfO-0GG4 i <br />DESCHARGE MONITORING REPORT (DMFt) <br />_ ,. ~~~~ <br />`'PERMfTNUMBER DISChARGENUMBER ~- -~~ a <br />i <br />~: <br /> <br /> <br />a ~l ~' <br />m <br />N <br />a <br />m <br />0 <br />o .~ <br />tv <br />iu <br />U <br />LL <br />O <br />la <br />z 1 <br />'~ <br />z -' <br />a. <br />Z <br />W :.,~ <br />z . <br />>~~ i~ I.~ I{ <br />a <br />a <br />~ ,..~ <br />C7 <br />,' <br />FACILITY - - _ _ MONITORING PERi00 .. - <br />_ ;, ,, <br />.., <br />, <br />l <br />_ <br />. YEA$ i~10 DAY YEAR M0•. DAY .._ <br />LOCATION _ -, -.. ; .;: FROM TO _. _ .... ,. <br />~ y <br />•~ ~ ~~; ~ r;; ~ ~;r' ~ ~ ": " : r NOTE; Read Instructions before <br />_ „ completing thisfi~n, <br />', PARAMETER QUANTITY OR LOADIPlG QUALITY OR CONCENTRATION N~, FREQUENCY ~MpLE <br /> <br />~ OF <br />EYPE <br />i ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />,., <br />~ `t <br />i <br />SAMPLE <br />;,: ~ t,.t:.,{ - <br />.- <br />=~ ~; :• ? <br />.. ~•: . <br /> MEASURE <br />MENT <br /> 1[[ <br />. ,. ', .. <br />~ <br /> <br />1 Y e ,;,1 t E <br />r- ~.,J_~~° .. S t'~~.. . ~t~ `_' <br />~ I <br />s ~.~ <br />REOI~I~~ SNT I I <br />_ ~ <br />,^ <br />; i ~ ~` <br />~~' I '' I ~ '": °~Ir, <br />' <br />' SAMPLE ~ ~ ~ 'I ~ .- ~ - , ~ . _ <br />~ <br />~ ~ ',~ ~` E <br />;; f r <br />f i~ <br />~~s~ MEASUREMENT~ <br />j <br />~ ~~~SC~u/ iJ <br />-- <br />~;. + ~ j . ~~ P~F~kT r ... rtt it-, ~. ~ ~ _., <br />trl ..,_.1:'I E~;4~a~. kf-.?efF <br />.~ REQ,~x`F~~TI <br /> <br /> <br />,M „ <br /> <br />_ i. ~. <br />I „1,.~. <br />I I rf~s;'j ~ t ~ <br /> <br /> <br /> <br />. <br />r ! ~__.~ <br /> <br />. l~ _ <br />... - <br />~. <br />SAMPLE <br /> <br /> <br /> <br />I <br />.. I <br /> <br /> <br />~ <br />; -; <br /> MEASUREMENT ~ <br />„ ,.,., _ ~~r 1.3_ ~ <br />I _ _ <br />Viz,. t t.=~ ~`;* `: t.'1~;:; '~'.;E ~.; RE04Y-E'A~ENT <br /> <br />,,;,, . „ ~ i ~ ,~..:~ <br />- -- ~y~~~%f._ <br />- <br />I . ~ ~ I <br />"`' ~ I ~' 1' i SAMPLE _ , , ;,.; ~ j <br />r .~,'r <br /> <br />I MEASUREMENT I <br />I <br />t s { ;i <br />~ <br />PE'}'~~'. <br />~ <br />v <br />d <br />A ~ t i , ~1 .- <br />1 r~ ~ii~-, ~,f~lP AEQ~{([~~NT , ., ~ i ~ ~ +`L ~ - ? <br /> • SAMPLE <br /> Ea`. ="':::' MEASUREMENT <br />' 3 "' n~1~i`t ~ . <br />i <br />` t` L fr._.i ,. ~ ~, _ . V }i_ 11 REOI}1xtf~(t~~tJT ., ~ a ..r .` ,. ~ r' <br />'?T~.. .ii t`; ~'Sra:i:7:T SAMPLE 't .;a'~r:~^ ,.. ., ., ,. zt.,.,,:px R~~a...*;~ i .. <br /> MEASUREMENT <br />~. ~ <br />'hrti ~ .1 . <br />P~~~ _ <br />- . <br />_ ,. <br />~. <br />_ : <br />p, r; <br />r <br />~'-'f I i~,~ 1 Ur ~s ~ ' 1.9 <br />> .. rtt . i a .. ~'(kIT`rt _. t,. ri REC~~„NT <br />SAMPLE --- ?k- • -.., „ ,. ~. ,. ,. ;: ~ ~ ~ <br />~ .. ,.:,-s; -~ ,; WI ':+';,. ~ <br />~~ ~ <br />• , . , + .: i _..~~ : <br />,. <br />,... MEASUREMENT <br /> <br />~ <br />n, ~ <br />_ Fvll`f <br />,:, <br />- <br />~ <br />~ ~ <br />~~'~ tl_i~T _~r~`~:~,'? ~~ ii.. <br />~ ~ ` REOUCkiRENT I ~ ~ ' i~P:1 <br />~ - ~ - -- - ~„ ~ <br />NAMElTITLEPRINCIPALEXECUTIVEOFFICER Icerfifyunderpenauyonawthatthisdacumentandallattachmeatswerc TELEPHONE DATE <br /> <br />"' <br />' prepared under my direction or supervision in accordance with a system designed <br />TT~ ~ <br />T, <br />r <br />(~;`~ p,,,, Jam' ~ to assure that qualifiedpersonnel property Bathe[and es~luate the information <br /> submitted. Based on my inquiry of the person or persons who manage the system, <br />1 ` 1 or Wose persons directly responsl6le for gathering the information, the information <br /> <br />U Y I <br />1 , O (Jp,~'r0n l <br />submitted is, to the best of m knowled a and belief, true, accurate, and com lete. <br />fam aware that th <br />i <br />( <br />t <br />it <br />lti <br />f <br />b <br />i <br />l <br />NATU OF PRINCIPAL EXECUTIVE <br />,^ <br />v q <br />T <br />~ ~',~~~ <br /> <br />O~ <br />/~ <br />V <br />;TYPED OR PRINTED ere are s <br />gm <br />can <br />pe a <br />m <br />t <br />e5 <br />or su <br />ng fa <br />se information, <br />including thepossibilifyoffineandimprisomnentforknowingviolations. FFlC RORAUTHORIZEDAGENI AREA NUMBER YEAR MO DAY <br /> CODE <br />;; <br />rr.~ <br />e~~ <br />d ld, f' <br />.. COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference alt attachments here) <br />s <br />i k 1:! a ('f i ~._ ;, t. ~' s.. '~ ~,. ,. ._., `~' _. .. _.. _ ,,.. _, 4. .,, ,. `~~,.,}.~~ !'t ..i~l z i- - A <br />~I <br />hl :I'~;i <br />;~ <br />