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PERMITTEE NAME/ADDRESS,,,;, NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) Form Approved. <br />OMB No. 20404004 <br />NAME O DISCHARGE MONITORING REPORT (DMR) <br /> ?! <br />ADDRESS <br />Q TO <br />ToOv <br />PERMIT NUMBER DISCHARGE NUMBER <br />NAL. ROLAN <br /> <br />DI FOND TO 5CULL.IOtIN (Ul- <br />F <br />` <br /> MONITORING PERIOD - <br />- <br />FACILITY v <br />J R? <br />y YEAR MO DAY YEAR MO DAY <br />a <br />LOCATION. a'Cjd TO <br />NOTE: Read Instructions before completing this form. <br /> FREQUENCY SAMPLE <br /> NTRATION <br />C NO, <br />PARAMETER QUANTITY OR LOADING E <br />QUALITY OR CON OF <br /> <br />ANALYSIS <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE -; <br /> MEASUREMENT <br /> - <br /> :; 5 r. . <br />_ PERMIT f t k <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />_ PERMIT <br />?•-i REQUIREMENT <br /> <br /> SAMPLE <br />I <br />rl <br />?i ' :? <br /> MEASUREMENT <br /> <br /> PERMIT <br />- ;: I , : • REQUIREMENT <br />( SAMPLE <br />t <br />C <br />• ? / <br />/fir <br />?? <br />` <br />- MEASUREMENT ` ' ? <br />,e <br /> PERMIT <br />i (J'. REQUIREMENT _ <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT G EN17 <br /> <br />- <br />' <br />' SAMPLE <br />MEASUREMENT <br />7 <br />. <br />rue: <br />r. i ' <br />! <br />l r <br />. t ?} x f <br />C <br /> PERMIT J. . <br /> <br />-, s r REQUIREMENT <br /> SAMPLE <br />6 16) <br />? Aj <br /> MEASUREMENT <br />T <br />- <br />1. R EP <br />PERMIT <br />REQUIREMENT <br />IMU PRINCIPAL EXECUTIVE OFFICER I Len,fr under penalty of law that this document and all attachment were TELEPHONE <br />NAME <br />d <br />d DATE <br />. <br />esigne <br />_ <br />prepared under my direction or supervision to accordance with u system <br />aware that qualified personnel properly gather and evaluate the infomianon <br />h <br />e system. <br />- submitted Based on my inquiry of the person or persons who manage t <br />i <br />on <br />or those pcrxrnv directly responsible for gathering the information. the informat <br />UMmitcd is, to the beat of my knowledge and belief, true. accurate. and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />l I am aware that there are signifiatm penalties for submitting false information, OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />_ <br />TYPFD 1 R PRINTED ?duding the possibility of fine and imprisonment for knowing violmions. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />I _;A Form 3320-1 (Rev. 3,W) Previous editions may be used. <br />RECIP. EVENZ' - SEE I. A. 1, PG. 3. FOR R1 <br />MPLING INSTRUCTIONS - I. C. 7. , Pty. 14. <br />PAGE OF