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PERMITTEE NAMEIADDRESS dnelnde FacilityName/location if Dtjfrrrntr <br />NAME <br />ADDRESS <br />J N <br />FACILITY NU -j I M, <br />LOCATION ?N t1A <br />A MI C•? <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D 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.OD04 <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX YSIS TYPE <br /> ANAL <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />- <br /> PERMIT <br />F <br />1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br />NAME MLE PRINCIPAL EXECUTIVE OFFICER I ce.16 under peneh} of law that this document and all attacbmem. were TELEPHONE DATE <br /> prepared uttder m% direction or supervision in accordance with a %)mrm decignrd <br /> to :Assure that qualified personnel properit gather and eealvate the inrormaliom <br /> submitted. Ravel on m) inquire or the pe-it or Pon- who manage the system. _ <br /> or those prisons dirmtIs responsible for gathering the information, the information <br /> wbmilted K. to the hest of m% knowledge and belief. true. accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE <br />' I am a. a" that them are signifts•ant Penalties for wbmitting false information. AREA <br /> nt for kno%ing siolutions <br />f f <br />d i <br />isonm <br />cl <br />di <br />h <br />ibili OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />b o <br />ine an <br />mpr <br />e <br />in <br />u <br />ng t <br />e "% <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments nere) <br />T'F C1 AIM APPRQ`,1FD rY WOCD. <br />1111? iC fi •?-P:11I <br />EPA Form 33201 (Rev. 3/99) Previous editions may be used. PAGE OF