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PERMITTEE NAME/ADDRESS (Include Hacrlim M14me-Location tfGN r erenn Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) OMB No. 2oaooooa <br />ADDRESS ! ' r n ! <br />PERMIT NUMBER DISCHARGE NUMBER F• 11.4AL t4HL_ <br />-,: <br />FACILITY MONITORING PERIOD RFD WASH <br />- " <br />LOCATION YEAR MO DAY YEAR MO DAY <br />FROM TO <br />NOTE- Raad instrnrtinna hafnra rmmnlatinn this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREDUENCY SAMPLE <br /> <br /> <br />>< <br />EX OF <br />TYPE <br /> <br />- AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -. i i <br /> REQUIREMENT w: - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT AVC, <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />,i ; REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />f REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -IV -f'r=.i' <br /> REQUIREMENT - r_r? •; t <br /> SAMPLE ",:3" <br />sr i ;= <br /> MEASUREMENT <br /> PERMIT r :? ...w If <br /> REQUIREMENT - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT Frizz TRi <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cemfl under penaln of law that this dmwumeot and all artachmems Acre TELEPHONE DATE <br /> prepared under my dtrecnnn ur,uperciston in accordance w nh a svstem designed <br />t <br />l <br />l <br />h <br />fi <br />d <br />l <br />h <br />d <br />- <br /> o assure t <br />at qua <br />personne <br />pnper <br />i <br />e <br />y gat <br />er an <br />evaluate the mformalim - <br /> submitted- Based on my mquirt of the person or persons who manage the system. <br />' or those persons dircetly responsible for gathering the information, the information <br />r?` • , <br />,-" submitted is <br />to the hest of my knowledge and belief <br />true <br />accurate <br />and cwn <br />loe <br />r , s, <br />. . <br />, <br />. <br />, <br />p <br />h <br />i <br />l SIGNATURE OF PRINCIPAL EXECUTIVE - <br />^ ?' <br />TYPED OR PRINTED <br />r.rs.... r..?., ..... ?..... ....?.......? ..... ...... I am aware t <br />cant pena <br />at there are signif <br />ties for submitting false inIornat;r,n. <br />ncluding the possibility of tine and nmprisemment for knowing rrdanon, <br />.?....... ,.. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />CODE YEAR MO DAY <br />on orac..nn.cnw nmc/ <br />0L: C <br />A h(), f) 3320.1 (Rev. 3199) Previous edftions may be used. 0022' This is a 4-Part form.