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PERMITTEE NAME/ADDRESS, /,: ; udr 6Yxrfim .Y u»t2rK mmn iJDlJI.•nrur <br />NAME <br />ADDRESS <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 />PARAMETER QUANTITY OR LOADING QUALITY OR CON <br />CONCENTRATION <br />NO. FREQUENCY SA <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r<. <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _ r,:.., •. <br /> REQUIREMENT <br /> SAMPLE <br />". MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I under penaltN of Ltw that thl, d..sument and alt,maclunenr werc TELEPHONE DATE <br /> prepare.i under m} dtr am or super%isiun in accordance with a ss: tem de;ignmi <br />n, assure that yuai I fie d personnel properly gather and esaluale the mtt rrnauon <br />- - --^ <br /> <br />submitted Based on ms inyuln of the person or perm r who mama the +y <br />stam. - <br /> or those per ons dtr "tty resporable for gathering the information. the infornnon <br />m <br /> submitted is, to the best of my knowledge and I+chet, true. accurate. and complete <br />1 am aw are that there are sicmitiwnt nenah,es fir.nhnun-, fala lofolmanml SIGNATURE OF PRINCIPAL EXECUTIVE yG ??`? ???L L <br /> <br />MPLE <br />Ci G' <br />1 YrQu Vn rriwo f CU I I,:e pUticlhlll[? "I Ilile .ln.1 I lllpr:al?tl!11?11[ tL.'. i' 1, I:I?w lilg e'IUlall• <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />- ...,?., - --I1.-.,.«..-- I I CODE I NUMBER <br />This 1S a 4-part fonll. PAGE <br />Irrn Approved. <br />MB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />EX OF TYPE <br />