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PERMITTEE NAME'ADDRESS rhu hide <br />NAME <br />ADDRESS <br />FACIUTY <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 />Form Approved. <br />OMB No. 2040-0004 <br />X <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE I MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT " <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x z ., <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT k? * . ?... <br />i REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />r i i REQUIREMENT +'. <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ! s = . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER 1 unify under penalty o] law that this docunicm :+nd all armchments were TELEPHONE DATE <br /> prepare,] under in% dirmiton or supemmon m accordance with a syswrn designed <br />kiehard A <br />Munson to assure- that qualified rcrsonnel propvrh g:nhcr and cs aluatr the mtnrntaunn <br />. submitted. Based on my inquiry' of the person (ir prr>ons who tnanage the :)-stern. _ <br />Vi <br />P <br />id <br />t or those persrns dir ctls responsible for gathenne the information. the mtlvrnation - -? <br />ce <br />res <br />en brnuted i <br />to th <br />best <br />e and Iklief <br />true <br />accurate and complete <br />f m <br />knowled - ' .t y 1]%I C ? (' <br />? <br /> p <br />. <br />. <br />- <br />su <br />s. <br />e <br />o <br />g <br />l <br />f <br />b <br />i <br />if <br />l <br />o SIGNATURE OF PRINCIPAL EXECUTIVE - - _ <br />TYPED OR PRINTED or >u <br />ni%iung fa <br />se mt <br />m+anon' <br />I am aware that [se are s <br />gn <br />icant pcna <br />nc; <br />ncluding the pnss:erbi6ty of fine atkl rmpnv mntm Fir knowing cuoln ons. OFFICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER YEAR MO DAY <br />VMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />:va;us eda o^5 r a!; " Thil is 3 -part tiol'lll.