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PERMITTEE NAMEiADDRESS t/n,/.d, Fxelin .Nunr2orunwr fJOtJfcrrrlr} <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 />NOTE: Read Instructions before'completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SA <br /> EX OF <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r< <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />F <br /> EQUIREMENT <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/TTfLE PRINCIPAL EXECUTIVE OFFICER r r, under penalty ..t taw that this d wunum .md .ill .uterhments wrre <br />. TELEPHONE DATE <br /> prp.ned under my Ch <br />ICO vt Or .uponlSIOn in accordance wvh a ty tem designed <br />-- to assure that qualified pernnnel properly pilfer ,md eo-ubrate the information <br /> submitted Based on my inquiry of the person or persons u hu manage the system. - ?- T? -. <br /> or those persons dtr qtly resryrnsible for gathering the mtormaunn. the tntom at-i <br />r ! submitted is. to the best of my knowledge afht belief, true. accurare• and complete <br />I <br />a <br />th <br />t th <br />ar <br />lk <br />lti <br />itt <br />t <br />f <br />b <br />f <br />l <br />i <br />f <br />d SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED am <br />ware <br />ere <br />e stgni <br />pena <br />es <br />or su <br />a <br />an <br />m <br />ing <br />a <br />se <br />n <br />orma <br />nn. OFFICER OR AUTHORIZED AGENT AREA <br />.n•: Riding the possihdtn of fine and imprisonment for knowing rrolamons CODE NUMBER YEAR MO <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />MPLE <br />TYPE <br />EPA Form 33241 (Rev. 3/99) Previous editions may be used. This '1S a 4-part fonn. PAGI