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PERMITTEE NAME/ADDRESS NncludeFixtilrp 4',rmrL•,urmn JDrllrnnu <br />NAME <br />ADDRESS <br />iNIL, <br />FACILITY L, <br />LOCATION. T nI" <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY <br />FROM I YEAR MO DAY <br />TO <br />HAi- A <br />Form Approved. <br />OMB No. 2040-0004 <br /> <br />PARAMETER r•.., ?. nnau instructions oer ore co mpleting th is form. <br /> QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. FREQUENCY <br />FREQU <br />OF <br />SAMPLE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE I <br />A ANALYSIS TYPE <br /> M <br />XIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PE . <br /> RMIT . b S # <br />- <br /> <br />• `.`-? ; ,':,L <br /> <br />REQUIREMENT i <br />x r <br />-_ : <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ins:•li# <br /> #fi3e k+tr c :-? '• if #iiifx i =r. <br />j <br /> <br />- L .i. <br />REQUIREMENT i <br />.- <br /> Y rA ,v'. <br /> SAMPLE I <br /> <br /> <br />- ' <br />MEASUREMENT <br />A <br />I t- v <br />) P <br />R tr# s k # R <br /> E <br />MIT #r. t s: lJ R t <br />; <br />7- <br />`J <br />AL <br />REQUIREMENT <br />: R <br />- <br />.. <br /> <br /> SAMPLE <br />' MEASUREMENT <br />~ / <br /> / <br />l <br /> PERM a: •o•tt;:•tE# • <br />: ? <br /> IT n <br />#i a <br />-'c, ? 4 l <br /> <br />r , I <br />REQUIREMENT _ _ <br /> A V 6 <br /> SAMPLE rz <br /> MEASUREMENT <br /> <br /> P <br />R s:.,. ;. q. R <br /> E <br />MIT #t a r sr r , ?s s r +• :< rF tt i J <br />. <br />F L'JE tV T 4 ? I5 4S '•? ,aL : j: REQUIREMENT . . Ly <br />•Ir+ .I i'J '_ Cr?11„ SAMPLE <br />U ?RF A rMEr.; al r.r.l <br />r MEASUREMENT <br />_ PE <br />MI P; PQ R- F -; <br />' <br />' R <br />T . st## .? 7, <br />F L <br />J1 <br />i i. _?^S REQUIREMENT .-N <br /> <br />L 1 <br />L,; <br /> SAMPLE <br />I SUAL MEASUREMENT <br /> <br /> PERMIT -- FU y r <br />r Y <br />- <br />- <br />^ <br />x <br />` A <br />. R zc- A Sr s. ! <br />REQUIREMENT t_ ; _' fi ?. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ccrtrh under penalty of law that this document and all attachments were <br />- prepared under my duecuon or supervision in accordance with a .,;v tem designed ) TELEPHONE <br />/r ? '?' - /,'- c essurc that qualified <br />l' ' <br />personnel <br />" <br />? •- <br />r <br />J <br />l <br />t DATE <br />- <br />. <br />/ <br />. - - <br />, r <br />` _ <br />_ proper <br />y t?at <br />tcr and evaluate the inl rmnnon <br />-ubnuwd. Based on my mqurn of the <br />no <br />• <br />+ <br />h <br /> <br />i -- pc <br />n or f <br />rsnn. w <br />a <br />o manage the system. <br />r those perwns dtrRtl <br />rcs <br />n <br />bl <br />f <br />h <br />1• <br />. <br />' - <br />? ' <br />? <br />t <br />/ po <br />y <br />st <br />e <br />or gat <br />cnne the information, the mtormation <br />sUbmrttcd r <br />t the he t of <br />k <br />x I <br />h % <br />' <br />' - r <br />'-` <br />' <br /> <br />. <br />rm <br />r <br />dec and <br />clrct tntc a.cumtc. and complete <br />I _ <br /> <br />TYPED OR PRINTED <br /> <br />ant awar r n dr a• a:c .:c nr f* .a na, !,.T .; hrmrunc fake information, <br />r <br />l <br />di <br />' SIGNATURE O <br />F PRINCIPAL EX CUTIVE <br />? "' <br /> n <br />u <br />c <br />ni tiro pn:.d+;un nr fine smi unpnammc+.;: i,?.? kn <br />c elation., OFFICER OR AUTHORIZED AGENT AR - - <br />COMMENTS AND EXPLANATION OF ANY VIOL ATIONS (Reference all att <br />h CODE NUMBER YEAR MO DAY <br /> ac <br />ments here) <br />`' I i Sl '?UR I NG PERIOD REPORTED. CI T L & (-?RFASE -FEE 1 P, P ? r`7-; <br />7DTAL- I." T T IS _B E_ <br />F I- F ,. {j -, a. _ -... ,,; be used. _ <br />? .J L"'2' c This is a 4-part fornl. PAGE OF