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PERMITTEE NAME/ADDRESS driclude FacUlry Ncww/Lourrlon i1Di/jerend <br />NAME <br />ADDRESS <br />iI Q 164 <br />FACILITY pl 1. i ':t <br />LOCATION;-. -LY 3164f <br />.1 1-? T I 1 6i= n. M T tUF pit"ARIAf-'FR <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 />Form Approved. <br />OMB No. 2040-0004 <br />0LL <br />R3LAN <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />_ SAMPLE <br />r, <br /> MEASUREMENT <br /> PERMIT ;i HEi TRLY 3RA1' <br /> REQUIREMENT aQDi'•. <br /> SAMPLE - r <br />'JF?f MEASUREMENT <br />- PERMIT y <br /> REQUIREMENT <br /> SAMPLE !_ < ! <br />E, <br />; MEASUREMENT <br />. PERMIT t ? <br /> <br />- - REQUIREMENT `i',? At? r <br /> SAMPLE j _ <br />r '.. <br />- _ MEASUREMENT <br />. PERMIT t r „ <br /> REQUIREMENT I f t <br /> SAMPLE <br />~ <br />Cl <br />r ; <br /> MEASUREMENT C r <br /> PERMIT °Et'CPT REPORT <br /> <br />IREMENT <br />REQU <br />J I V I`;., <br /> SAMPLE <br /> <br />< D . oZ <br /> <br />O <br />;?-_ <br /> <br />G <br /> <br />'? <br />? <br />? <br />/ <br />?ayc <br /> <br /> <br />TG MEASUREMENT <br />, <br />( <br />, <br />. <br /> PERMIT tr.t#rt. i;FFC?F3T 7`Y ;!?r'P <br /> <br />_ REQUIREMENT <br /> SAMPLE ) <br />1 <br />G f <br />t t ` <br />`• <br />- MEASUREMENT / ` 'a <br /> PERMIT i.Eo .RT RF_P OP 1_r•° t':?;_'• <br /> REQUIREMENT P' I 1_ y MX <br />NAMEfITME PRINCIPAL EXECUTIVE OFFIC I certify under penalty of law that this document and all attachments were TELEPHONE DATE <br />prepared under ma direction or supervision to accutdance with a system designed ; <br />to assure that qualified personnel properly gather and c,aluatc the information -- _ / <br />suhmmed. Based on my inquiry of the person or persona who manage the system, <br />or than persons directfy responsible for gathering the information, the information <br />L' / submitted is. to the best of my knowledge and belief, true, accurate. and complete. <br />• SIGNATURE OF PRINCIPAL EXECUTIVE -7 <br />I am aware that there arc significant penalties for submitting false information, <br />l <br />i <br />f <br />i <br />i OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />or know <br />at <br />oru. <br />ng v <br />o <br />TYPED OR PONTED including the possibility of fine and impnsorunent <br />COMMENTS AND EXPLANATION OF ANY VIOLATION5 (Reference all attacnments nerej <br />OOOG- ;This iS a 4•jTan form.