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PERMITTEE NAMEIADDRESS (include Fncilin \amt I o-it-n if lhfjrrenrr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />'4t.4 I IN <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 />NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO <br /> <br />NO. <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 /> <br />PERMIT ,.. ?..fi <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif, under penult. „rlaw that this doctttncnt and all alladtmrnts were TELEPHONE DATE <br />prepared under my direction or supersi+am in accordance with a system designed _ f <br />1 <br />h, a. ure that gmdiried perwmnel properly gather and rrulualc the information -?? <br />suhmitt d. Ra+ed nn m> inquiry of the per,jm or {a•nons who manage the y+trm <br />\ <br />r <br />,r thaw- lx•r+ons dine th ra p,mible h,r gathering the inrornmtimt. the information <br />_ I <br />knowledge and Iwlief, tear. aauratr. and complete. v <br />('?_ <_. L? submiUed n. W the F><t of my <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />V ?•? <br /> 1 am aware that there are significant penalties ror submitting false information, AREA <br /> d im <br />rim <br />ent far knowing+iolatioms <br />di <br />th <br />ibili <br />i <br />l <br />rfi OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />ng <br />ty u <br />nr an <br />p <br />mm <br />nc <br />u <br />e p- <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here <br />PAGE