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PERMITTEE NAME'ADDRESS rbuhld,F-ovdin Namr4.x:aw,,njf #errnp <br />NAME <br />ADDRESS ?z- Ann rimer <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 />orm Approved. <br />)MB No. 2040-0004 <br />NOTF• Ranei Inctr{,Minnc Fwfn.ai! ..lafinn fhic fnrm <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />X OF <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS E ANALYSIS <br /> SAMPLE <br />1r MEASUREMENT <br /> PERMIT !?r <br /> REQUIREMENT <br /> SAMPLE <br />i t F' 4t, 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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cemfy under penalty of law that this dcwument and all attachments werc <br />TELEPHONE <br />DATE <br /> prpa:e,t under my dircenun or supcni+ian in accordance wnh n sraem designed <br />L-Ott-?S??YC to assure that qualified pcrwmncl properly gathcr and evaluate the ,nfumtatirnt <br />submut -d. Rased on my inquiry of the person or pctum% who manage the sy%tent ---/-, - <br /> <br />l . <br />or those persons directly responsiblc for gathring the information. the information <br />i - ?: ?• submitted is, to the best of my knowledge and bchef. true, accurate. and com lcic <br />I <br />th <br />h <br />fi <br />l <br />b <br />m <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> am aware <br />at t <br />ere are signi <br />cant pena <br />ties for su <br />mitting false m(armnu, <br />. <br />TYPED PRINTED <br />............?.. ..... ?..... ...._.,....... ........... hiding the;x- b,hty of tine and impnsonmern for knowing violation. <br />.......... ._ OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODS YEAR <br />. MO DAY <br />all aria {.111lICII{J IIC/C1 <br />EPA Form 33201 (Rev. 3,%) Previous eddions may be used. Q? This is a 4-part form.