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PERMITTEENAME/ADDRESS br<rud.l:r,irr, ~",,:, i ,,:n~.:!Ir.'r<,,r:: <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (O R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />r-sa_ <br />U l~.f <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY <br />of SAMPLE <br /> EX I TYPE <br /> ANALYS <br />S <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> ` <br />i 3 '2~O ~ II~ I~SI~ <br /> MEASUREMENT fir' <br />' <br /> ~ ~ ~-; i <br /> PERMIT ~' _ , <br />~ <br /> REQUIREMENT - <br />;:- ..~ <br />~ ' i'1;:~' - '~-+' ~ ` <br />~' <br /> SAMPLE r,.~ C,'J `'~, ~ I~ ,._-4'.>F3 <br /> MEASUREMENT <br /> PERMIT ; <br /> REQUIREMENT ~~ F,'; ~`'I~ <br /> ! _ ` < ;_-~' ~ ;~~ Z ~~~ C~~•7~ <br /> MEASUREMENT <br /> PERMIT - ~ ~ ~ ~~ <br /> REQUIREMENT <br /> SAMPLE ~,~~ <br />~ -t 1rj <br />f-T !~ <br />~l ~ l~ ,~`('•~'~ <br /> MEASUREMENT - <br /> PERMIT 1 t.. L- : ~ - ~ .. <br /> REQUIREMENT • <br /> SAMPLE <br />~~ <br />~ <br />~~ 2 <br />~ ! r <br />~~~~ <br /> MEASUREMENT ' ' '` <br /> PERMIT r, ~~r;;.: r _ -. _ <br /> REQUIREMENT <br />;ri-, <br />_ ''•'JL'-- ~4 ~ .._ }•' <br /> SAMPLE <br />MEASUREMENT <br />(-.y~L- <br />3.~~ f <br />~~`-~ <br />~ <br />ir~'~ <br /> - ~, , ~ _ ...... , _ _ . - <br /> PERMIT <br />REQUIREMENT - - <br /> SAMPLE n,( <br />~ <br />' ~ <br />v I; <br />~1 <br /> MEASUREMENT yJ ~ " <br /> PERMIT ' <br /> REQUIREMENT - .' <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I rerlih wwler prnaln ..f law Iha~ mi. drMOmrm and au almehmenls were --- - <br />~ TELEPHONE DATE <br /> pnpurrd under m}~ dlreHhm or erprn hion in acrartlnncr wllhr ss+fem designed <br />informalum <br />l <br />lh <br />and r+al <br />wie th <br />h <br />lif <br />d <br />l - <br />1 <br />'<- ~ <br />~ <br />~~ ~ <br />, <br />Y pmper <br />~ ga <br />rr <br />i <br />e <br />In awwre T <br />at qua <br />ie <br />prnonne <br />rr.nn nr <br />rrcon+ who mam~~e the ry>Icm <br />in <br />uin nP the <br />h <br />iued <br />R <br />+ <br />d o „`J <br />_ ~' <br />, ~ . .. ~ ~., ~ <br />~ <br />.~ <br />, . <br />~ <br />_ . <br />p <br />p <br />m <br />. <br />s <br />e <br />n my <br />y <br />su <br />ur Muse persons dirn~ll~ rr.p:nsible for gathering Ihr inGxmaiiun. the informatMn - - - ~, ~ r - : <br />~ - ~ <br />` <br />_ t <br />iel <br />d <br />h <br />lkf <br />d i ~~ <br />' - L~ i <br />I > <br />l ~ <br />i ./ L' +" <br />\ ' <br />~ ` f <br />~ <br />L <br />` r, an <br />ramp <br />e. <br />ge and <br />r <br />, iruc. aarurr <br />submitted is, w the best of my knowle SIGNATURE OF PRINCIPAL EXECUTIVE - <br />i <br />/ -- ' <br />~/ <br />' <br />~ ` ' <br />~"'C- ` <br />- I am aware that Iherc are si>inffkant penultir+ fur suhmittin>:lalse informatNm. AREA <br />TYPED OR PRINTED inr•Iuding Ihr pn+ibiliN of Toe antl imprisnnmrnl for knowing vndalioro. OFFICER OR AUTHORIZED AGENT NUMBER <br />C D YEAR MO DAY <br />COMMEIVI' AIVU tAF'L.ANAIIUN Ut ArvT VIVLA IIVFYA Inr~rre~icr tin nuawnncrna ,rm c~ <br />~F~ :oo^~ p~. : r'. oro~r.... ,.. - --- _ - i'1 i'• l~ ;1 ~ ~IY.11~~ lie. --- -- ~,: ,. ----~~)F--- <br />