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PERMITTEE NAME/ADDRESS llncfude Faeilur A'ame/1 ation if Afferenti <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 YEAR MO DAY <br />FROM 7±n TO <br />F,?,n- Approved. <br />OPAL 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 }? 3 2 I(} Inl SI r. l <br /> MEASUREMENT <br /> PERMIT r. <br /> REQUIREMENT <br /> SAMPLE = /:' _ ?7 v <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT :f.9, . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT #t __ t s <br /> REQUIREMENT <br /> <br /> SAMPLE -• <br /> MEASUREMENT - <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE f, I V I ?Jj?L <br />_ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />PRINCIPAL EXECUTIVE OFFICER <br />NAMEMTLE I certify under Iattalts of laa that this d,wumrnt and all attachments lterr I TELEPHONE DATE <br />r prefrared under my dirretion or scapen t%ion in accordance with u system designrd j <br />C,! )ai- :1 L to assurr that 41wlirted pere,mad proprrly gather and er alurtr the information -?^--i?__.y?_ ?1'/ <br />t submitbd. Bawd on m7 inquiry of thr penon or por-as aho manage the Ntem, <br /> or three prrv , dirrril) resp,msilde for gathering the information- the informatinn <br />- - d b <br />t <br />o <br />lete <br />d <br />li <br />f <br />d { l ` ? I I k <br />" _ - , trur. arcurr <br />r, an <br />c <br />mp <br />. <br />whmitt,d w, to the hat of my knowle <br />ge an <br />e <br />e <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />`'' ` <br />" I am .,,.am that there am signifia-am penalties for wbmiuing false information, AREA <br /> risonment for knowing sitdati,ms <br />nd im <br />l <br />di <br />o <br />ibilm or fine <br />i <br />th OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED • <br />p <br />ng <br />e p <br />s <br />a <br />nc <br />u CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />., 'f ?:, 'I. Pre, 4, FOR REG!,-".F?LMF- <br />This-is'a 4-part form.