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PERMITTEE NAMEiADDRESS (Include Faeilirt NumeL<Narir,n rjDrj/en•nrl <br />NAME <br />ADDRESS <br />I. NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />tY <br />FACILITY DI <br />LOCATION Y <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 />ftEt_AN <br />NOTE: Read Instructions before comDletinq this form <br />PARAMETER <br />1 <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREQUENCY <br />SAMPLE <br /> >< <br />EX 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 ?t ;- ir; l C i R <br /> REQUIREMENT t, ^Si IP <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -a <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />L. ,• t-.`; REQUIREMENT <;_' IT <br />7:• SAMPLE <br />1 rr- r: MEASUREMENT <br /> PERMIT <br /> REQUIREMENT M; ; <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r) r, <br />NAMEIITLE PRINCIPAL EXECUTIVE OFFICER I certify under penaity of law that this document mxl all attachmcros wcrc TELEPHONE DATE <br /> pr-pared under ms dir rtion or supeni ion in accordance wtih a system designed <br /> <br />- to assure that qualified perawnel properly gather and esaluatc the mfornutton <br /> submitted. eased on my inquiry of the pet-a,n or per-ns who nuna¢e the system. <br /> of thosc pctwns dlru;.tly responsible for gathering the infomation. the mfoKmau„n <br />•, / submitted is, to the hest of my kno,sledge and hchcf, true, accurate, and complete <br />t th <br />fi <br />t <br />lti <br />b <br />I <br />th <br />i <br />f <br />itti <br />fal <br />i <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am aware <br />ere arc s <br />gni <br />pena <br />or su <br />a <br />can <br />es <br />m <br />ng <br />se <br />n <br />orma <br />on, <br />mcludmc the pos.ihdtq of!ine and impri <br />onment tor knowing i lununx OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />Y <br /> s CODE DA <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />F <br />EVENIT -- SEE <br />11'4STRUC T I ONE <br />This is a 4-part form.