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PERMITTEE NAME/ADDRESS rbr,dude Fat ilir,..?;rmr-7.cKatr n rjDi/re enu <br />NAME <br />ADDRESS <br />ELY <br />FACILITY <FID <br />LOCATION <br />,.. jTA%T ..- 10 ,f c._ 1:_P. INPDI-S <br />DISCHARGE MONITORING REPORT (DMR) <br />ti <br />PERMIT NUMBER DISCHARGE NUMBER i !AL <br />MONITORING PERIOD - <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />N (1TF• Rnnrl Ir <br /> <br />Y? <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> <br />? OF <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i;r'AE <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT y..- rF 1F; el is <br />i_;' REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a REF°C's .. ' . ; F•f_- Y 71 F? <br /> REQUIREMENT ; r•,? ,_ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT R C <br /> REQUIREMENT <br /> SAMPLE <br />_, - MEASUREMENT <br /> PERMIT `Z T' r- <br />`'L.- REQUIREMENT <br />•r I", X <br /> SAMPLE t'• ' <br /> MEASUREMENT <br /> PERMIT r <br />! REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT T ,? ! i= ;r.• _ <br /> REQUIREMENT , ;C `j f; <br />t?':r <br />NAME,TITLE PRINCIPAL EXECUTIVE OFFICER I ceniry under penalty of lau that this dceument and all attachments were TELEPHONE DATE <br /> prepared under my direction or suprn i,tun in aa•curdance with a systcm designed <br /> to assure that yuaiiticd personnel properly gather and evaltmic the mformanon <br /> .ubmned- Based on my myuiry of the person or persons "ho manage the ssvcm. <br />- -?" _"- or those persons directly responsible for gathering the intiomummn. the information <br />1.- - . ;ubrnita-d is, to the best of my knowledge and belief, true. accurate, and cumplr:c. <br />th <br />t th <br />I <br />i <br />fi <br />l <br />k <br />f <br />h <br />f <br />i <br />f SIGNATURE OF PRINCIPAL EXECUTIVE _ <br />J <br /> am aware <br />a <br />ere arc s <br />gni <br />cant pena <br />ties <br />or ,u <br />rmu,ng <br />n <br />ormation. <br />a <br />c O <br />C <br />TYPED OR PRINTED including the possihilim of tine and imprisonment for knnwme swi.mom FFI <br />ER OR AUTHORIZED AGENT AREA <br />NUMBER YEAR MO DAY <br /> CODE <br />3320-1 (Rev. 3199) Previous editions may be used. ,7C„ This is a 4-part fonn.