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PERMITTEE NAMElADDRESS r/nclt de hbcilin• Same -Tocarion if Different/ <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 MC L7? <br />FROM TO <br />Form Approved. <br />OMB No. 2040-{X04 <br />MINUP <br />(SUBF <br />F - F <br />NOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . <br />EX OF TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> ' TKL <br />'f' fi <br /> I F•i 7 <br />%FF _ <br /> PERMIT <br />L-..... I REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />,_ t <br />• • <br />r :. <br /> PERMIT ; <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <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 /> <br /> PERMIT <br /> REQUIREMENT <br />TITLE PRINCIPAL EXECUTIVE OFFICER <br />ME I .crtity under penalty of law that thus document and all attachments were TELEPHONE DATE <br />/ <br />NA prepared under my direction or superr.tsmn in accordance with a system designed <br /> to assure that qualified peronnel properly gather and evaluate the information <br /> <br />?. submatt •d. Maud on my inquiry of the per.on or penny who manage Wa system. <br />the information <br />t <br />o <br />i <br />f <br />f <br />h <br />h ,: . <br /> orma <br />i <br />er <br />ng t <br />e in <br />n. <br />or gat <br />or thow persons duretity rc pcrosthle <br />-? submitted is. to the best of my kno .ledge and belief, true, accurate. and cornplefe SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are sigmtica n penalties for submitting fake mlorrnauon' OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />TYPED. 0`R PRINTED mcindirg the po mhdity of tin- and impm nment for knowing siolauons CODE <br />' COMMENTS AND EXPLANATIUN UI- ANY VIULNI Ivn0 Invrvrvvi.w are <br />Pave OF <br />Ihl; i• a a-i?ar: li?;tn