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PERMITTEE NAME/ADDRESS (include FordifY Name/Location if Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY !i ;fi j Z.LN r, MONITORING PERIOD <br />; YEAR MO DAY YEAR MO DAY <br />LOCATION L A FROM TO <br />Form Approved <br />OMB No. 2040-0?04 <br />MINOR <br />F - FIPIAL i?li• i <br />W I NY, , : TY <br />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO <br /> <br />. <br />FREQUENCY <br /> <br />OF <br /> <br />SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT] <br /> PERMIT . * i <br />R -1- <br />CI' O <br /> REQUIREMENT :G %f? I i._ `•' M, hipl dTt <br /> SAMPLE <br /> MEASUREMENTI <br /> PERMIT r <br /> REQUIREMENT , - V G Dr" F l_ .( 1`9 X <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT y I <br /> REQUIREMENT -' <br /> SAMPLE <br />,,- MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT 7777 <br /> REQUIREMENT _10DA r_ <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />t• <br />- <br />tl( <br />._ t <br /> REQUIREMENT - : ,`'• -: i i...'?: ?.; , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT AL G <br />NAME(TITLE PRINCIPAL EXECUTIVE OFFICER I cerur, under penult% or taw that this docurnent and all attachment were TELEPHONE DATE <br /> prepumd under my direction or supenisiun in accordance with a system M•signrd <br /> to assure that qualified personnel propeperl7 gather and rsaluate the inronnatiun <br /> .uhmi(". Bawd on ms inquiry or the person or pe-tt, who manage the ss stem. <br /> ersons diraYtl.s responsible fur gathering the informatiom. the information <br />or thuw <br /> p <br />t <br />t <br />d <br />l <br /> e. an <br />comp <br />e <br />e. <br />wbmitt<d is. to the be%l of nn knowledge and behoL true. accura SIGNATURE OF PRINCIPAL EXECUTIVE <br />-- I am uw are that them arc significant penalties for submitting falw information. <br />EA <br />AR <br />EA <br /> risonment fur knowing sbdatiwts <br />of fine and im <br />ibilit <br />i <br />l <br />di <br />h OFFICER OR AUTHORIZED AGENT NUMBER <br />C YEAR MO DAY <br />TYPED OR PRINTED . <br />p <br />e pass <br />y <br />nc <br />u <br />ng t <br />COMMENTS AND EXPLANATION Ul- ANY VIULAI IUrvJ (tiererence all aetnatttrtctrta newt <br />00051 ' :Tfiikji' 47-0i& biTn.