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PERMITTEE NAME/ADDRESS tlnrlude FariN %a m•;l.,cation if lhf errnu NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO <br />Form Approved <br />OMB No 2(141: <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br />OF <br />SAMPLE <br /> EX A <br />ALYSIS TYPE <br /> N <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE c l } 7 ?, I/? Ir.! f 7t 1 <br /> MEASUREMENT <br /> <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />` <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~ ~ - <br /> S <br /> REQUIREMENT <br /> SAMPLE °_.k \S <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />2 <br /> PERMIT -11 7-7 . ?. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />AMEMTLE PRINCIPAL EXECUTIVE OFFICER I crrtif, undrr pent' of Iaw that thir document and ao auaehmrnts Nert 1 TELEPHONE DATE <br />N prrpan•d undrr nrv direction or.utwr%rsion in accordance %ah acs tem doigard <br />- - <br />- lu assure that qualirted prr+onnel properfe, gather and e+aluate the information <br />.. _ -. -? + <br />, -\ • - uhmitted. Ra+ed on m) mqulrs of the w-n or persom who manage, the s%stem. <br /> ersons directi% re4mamble for gathering the informatom, the inbirntalim <br />or tho- <br />\ <br />j <br />I <br /> p <br />Mt <br />l - - -" - <br />_I L? t <br />l <br /> romp <br />e. <br />+uhmiltal r. to Ihr Ia•+t of np knuwirdgr and Iwlirf. true. accurate, um <br />SIGNATURE OF PRINCIPAL EXECUTIVE _ - <br /> i am aware that there are +tgmfirani penulti? for submitting false information. THORIZED AGENT <br />R <br />R A AREA <br />TYPED OR PRINTED imiudinL the Iai sibihtr of Me and impri.onmrnt fur knowing viniution+. OFFICE <br />O <br />U DE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />- ± F, :i, Pte' 1, rDF! '2ECl?J!`<FMEPI <br />9E• This isl a 4-part form. <br />OF