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PERMITTEENAMEiADDRESS.!».hrJ /ac,;,r. ?,m+, ! avrv•»ir:hi.„m+ <br />NAME <br />ADDRESS <br />FAC!LITY <br />!-OCATION <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 />PARAMETER QUANTITY OR LOADING <br />CONCENTRATION NO. FREQUENCY SA <br />QUAUTY OR CON <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />. PERMIT <br /> REQUIREMENT <br />NAME! TITLE PRINCIPAL EXECUTIVE OFFICER I ecrtd'y under pcnalrr of Iaw that this dtxutncnt and all attachments were TELEPHONE DATE <br /> preparcd under mr dtrcown sir supervtsum in accordance with a system designed <br />-- ::: asurc that qunitfied per ruici prnpcrh gather and csaluate the mLxnmuon <br />z"- /, f ubmithtl. Based on my ingwn of the p rwn of per-ms who manage the system, J-- - <br />// / - - - <br />! <br />1 <br /> or those perscros directly rc ponsihlc forgathering the inf rimunn. the information J <br />- <br />_ 44- <br /> submitted is. to the best of tm knowledge and belief-. true, accurate, and complete. SIGNATURE OF PRINCIPAL EXECUTIVE - I - •• <br />MPLE <br />' <br />- <br />I ]U? aw:ne' "I'll nie a ere 11gm nca., pee- I - f f 111' ,,1 <br />TYPED OR PRINTED mcludmc the I-i +htr of fine and ,mpr - +. t .- :..r .. ..+.,_ <br />:OMMENTS AND PLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />OFFICER OR AUTHORIZED AGENT nel r NUMBER YEAR MO DAY <br />COGc <br />Form Approved. <br />OMB No. 2040.0004 <br />X <br />NOTE: Read Instructions before'cbmpleting this form. <br /> <br />EX OF TYPE <br />Tins is a 4-{part form. PAGE OF