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I PERMITTEENAME!ADDRESSunsludcFucilu <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 /> <br />NOTE: Read Instructions before completinq this form. <br />PARAMETER <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION NO. FREDUENCY SAMPLE <br /> OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />1 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all anachment%were <br />prelxucd under my directiun or supen•ision in accordance with a sys'icm designed TELEPHONE DATE <br />_ <br />' to assure that qualified personnel properly gather and evaluate the information <br />?? l? <br />- <br />J <br />-Yi7? <br />: • <br />?• suhmine 1. Based on my Inquiry of the person or persons who manage the system, <br />or thou persons directly respotnible for gathering the mfonnation. the information <br />f %uhtnntcd is, to the bl,t of my knowledge and belief. true, accurate, and complete SIGNATURE F PRINCIPAL EXECUTIVE <br />I ., .i . •,arr are significant penalties for submitting false information. <br /> <br />TYPED OR PRINTED ;ua:r_c h posdnlity of fine:ntd imprisonment for knowing violations. <br />r.?uururc won runt wuwTt?u rvr wuv vn?. w.. rv w... ... _w_.._ .. . ... ... OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />R DETAILS OF <br />AN I SMS, AND r= <br />1320-1 eddiors may be used. <br />rrere/ <br />SIRE. REPORT L <br />TOX I C' I T'`{ TElil <br />r phis is a 4 -pan fonn.