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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different) <br />NAME <br />ADDRESS ' 1 3 s - _I <br />FACILITY <br />LOCATION L } x'_L <br />f <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 />r .. .> <br /> NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> <br />AVERAGE MAXIMUM UNITS <br />MINIMUM AVERAGE MAXIMUM UNITS OF <br />EX ANALYSIS TYPE <br />r-, SAMPLE <br />(2 &21 1 rl. MEASUREMENT <br />PERMIT , . ...,. , ,. <br />-" REQUIREMENT <br />.. SAMPLE <br />MEASUREMENT <br />• <br />PERMIT <br />L P n t REQUIREMENT <br />.. p <br />` • ," .' <br />" ? SAMPLE <br />, <br />:.., ?. ?I) : _• MEASUREMENT <br />v PERMIT <br />r n ._ <br />_ <br /> <br />_ . .. , <br />;4, • _- ., ,•,t REQUIREMENT <br />':., _. ... SAMPLE : s .. ri : •-:' <br />MEASUREMENT <br />r. PERMIT <br />:z r I i1=1@j :. ;.t REQUIREMENT <br /> s???< < ,try -r <br />I SAM <br />- ., PLE <br />_ . c:; . <br />MEASUREMENT .. <br /> <br />, <br />PERMIT <br />REQUIREMENT € I' t , <br />t SAMPLE <br /> <br />MEASUREMENT <br />PERMIT- - - <br /> <br />, <br />r t" _sF. `ti REQUIREMENT <br /> <br />_ SAMPLE <br />w <br />z' <br />M <br />EASUR <br />EME <br />NT <br />.. . <br />PERMIT IR, <br />s:• c,;3 ,, ?.., REQUIREMENT ? .. '.. <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty' of law that this document and all attachments wereµ <br />prepared under my direction or supervision in accordance with a system designed <br />to assure that qualified personnel properly gather and evaluate the information TELEPHONE <br />?.?^"-';' ATE <br />j <br />submitted. Based on my inquiry of the person or persons who manage the system • <br />, or those personsdirectly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and com lete. • r_t <br />1 am aware that there are significant penalties for submitteng raise information, -•SIGNATURE F PRINCIP L EXECU E <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT A E <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) E NUMBER <br />CODE YEAR <br />MO DAY <br /> <br /> <br />EPA For 3/99) Previous Form (Rev. editions may be used. <br /> - r Th1S•1S11 4- aft f'rm. PAGE OF ,,? <br /> <br />