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PERMIT-TEE NAME, ADDRESS, In, h.L 1::r \:rnr,e'Lrxatwn i/Di•rrntr NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FACILITY <br />YEAR MO DAY YEAR MO DAY <br />LOCATION FROM TO 777 <br />Form Apprgted, <br />OMB No. 2040-0004 <br />lip <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE i <br /> MEASUREMENT <br /> ' <br />)iCCJ f _ <br />-`• <br />I <br /> PERMIT Rr'. :'R T -Y E5-_ i iii 3rit?# ::r#s r : . , <br />, <br /> REQUIREMENT ?'?Ft.C <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 ccrnl} under penalr-f luw that this document and all attachments were <br />cnwiston m accordance Rith a s%stem dc-mgned <br />r ms due-ire or cu <br />d <br />nd TELEPHONE DATE <br /> prepare <br />u <br />p <br />e <br />to assure that yualifted personnel properly gather arxd ev aluate the information ' <br /> submtucd Based on my inquiry of the person or perons ,ahn manage the system. <br /> the infomation <br />atherme the mformauon <br />as directl <br />msible bar <br />th <br />er <br />res <br /> - <br />g <br />or <br />ose p <br />o <br />y <br />p <br />t <br />t <br />m <br />lcte <br />l <br />d beli <br />f <br />d <br />b <br />f <br />k <br />d <br /> , <br />me. accura <br />e, ;m <br />c.; <br />p <br />now <br />e <br />ge an <br />e <br />submitted Is, to the <br />est o <br />my SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there arr significant Knalne, for,uhnutnng false information. <br />, <br />m <br />, <br />n <br />t f <br />k <br />l <br />f <br />n O FICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED r <br />no <br />s <br />g <br />w <br />ons <br />nprt„ nnnn <br />a <br />nefudutg the Iws,ihthty of <br />ine and <br />COMMENTS AND EXPLANAI IUN OF ANT VIUL.AI IVNJ (rrererence art anacnmrnts nrrc/ r <br />''ECIP Et)Fr.;1- ,.'.)`:I.:. ?:?- TO MJRDEN OF PRd-?OF REPI'-tIPFi'•ENT?7 T"ti <br />EPA Form 33241 (Rev. 3/99) Previous editions may be used. l S .? Th1x'15,apart t:01Tn. PAGE OF