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PERMfTTEE NAME/ADDRESS (include Facili{r .Name/(arcafion if lVerent) <br />NAME <br />ADDRESS <br />70 <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION <br />CHARGE MONITORING REPORT (DMRDES) <br />) t NOR <br />)UBR JC ) <br />PERMIT NUMBER DISCHARGE NUMBER - FINAL <br />'SCHARGE TO TRIG <br />Form APved. <br />OMB No. 040-0004 <br />LEK <br />;BEN CO SIf_ MONITORING PERIOD <br />FACILITY :_CA jr:'ItgE COMPLEX YEAR MO DAY YEAR MO DAY <br />LOCATION -r FROM TO <br />NOTE: Read Instructions before completing this form. <br />FREQUENCY SAMPLE <br />NO <br />. <br />QUANTITY OR LOADING QUALITY OR CONCENTRATION EX of <br />TYPE <br />ANALYSIS <br />PARAMETER <br />AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />- <br />I? <br />SAMPLE <br />I <br />MEASUREMENT <br />PERMIT <br />ENT <br /> REQUIREM <br /> SAMPLE - <br /> EASUREMENT <br /> M <br /> PERMIT - T 1 _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> <br /> PERMIT i i•: x; <br /> REQUIREMENT <br /> SAMPLE l_ <br /> MEASUREMENT <br />t: <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ) 1 i c? <br />A ; r!. MEASUREMENT ' S _ . <br /> PERMIT <br /> REQUIREMENT <br />I <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ?- <br /> <br /> PERMIT <br />MENT <br /> REQUIRE TELEPHO NE D ATE <br />NAMElfITLE PRINCIPAL EXECUTIVE OFFICER I certil <br />prrpur y undersKnalty of law that t <br />ed under my dirn•tion or .u{ his du•umem atd all attuchm <br />n•rri+ion in wYOrdunce with eal+ wen <br />a system designe d <br />f <br /> it, asw rr that qualirted personnel p roperly gather and eealuale t he information <br /> submit ted. Rased on my inquiry of the perum or persons who m <br />f <br />tl anage the system <br />the informati <br />n , <br />on I <br />(`? <br />1 <br />J <br /> or thos e person, directly rte-item+iht <br />A ornw <br />e for gathering the in <br />accur <br />lief <br />true <br />e a <br />d b <br />l <br />d . <br />o <br />and complete <br />ate . <br />RINCIPAL PAL XECUTIVE <br />E J `- I ? <br /> submit now <br />ted is. tw the M•st of my , <br />. <br />g <br />n <br />e <br />e . SIGN URE <br />OF P R E <br /> I am. . are that there are signirav nt penalties for submitting fa lse information. O AUTHORIZ <br />CER OR <br />I ED AGENT A DE NUMBE R YEAR MO DAY <br />TYPED OR PRINTED includ ing the po sihilin of fine and imprisonment for Avowing s i,dalions <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence an affacfffrrvin6 "e wi IJ IP EVENT SUBJECT TO BURDEN OF PROOF