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PERMITTEENAMEIA SS(Include • ''- NATIONAL POLLUTA MARGEELIMINATIONSYSTEM(NPDES) <br /> PaclhtyName/Gocatn •nU :`'•r�.•€•yI`;.: DISCHAR NITORINGREPORT(DMR) <br /> L'L'6 _��.�a- (1(,L u_jlYJlF. "_ (2-16 �' — FZ'NAL <br /> NAME_ r (17-19J' <br /> ADDRESS 1lf,.^• 3c'��}���.� �..� � �� �,� r ('!71 ' i •STORMWATERj spore -?PG fi I',tNE <br /> r� ��_ ,� l ,i PERMIT NUMBER 1 DISCHARGE NUMBER w , <br /> f MONITbA -P RIO,D <br /> FACILITY ——_ —— .—r—.— +„' _ _ <br /> " YEAR MO I I DAY I IYEAR ' MO DAY <br /> LOCATION .� _ FROM1 U j, TO t1IYOR TfiT�Ii <br /> 04 <br /> (2021) (22-23) (24-231 ,(26-27) (8-291 (30-31J NOTE:Riadlkitru u <br /> ctfons before completing this forn' <br /> (3 Card Only) QUANTITY OR LOADING i(4Card rely) QUALITY OR CONCENTRATION REQUENCY i <br /> SAMPLE <br /> PARAMETER } j (46.53) (54-61) (38-45).. (4653) (54-61) EX i OF TYPE <br /> (32-37) u• AVERAGE j MAXIMUM I UNITS MINWIJM AVERAGE f MAXIMUM + UNITS (6263 YA(�L68)S i (69-70) <br /> I I. AND I-a F EAS E SAMPLE <br /> r I j L MEASUREMENT <br /> �4C6 -' cEKLY` 'l5UAL <br /> r b 1 0 0 PERMIT 4 ,' <br /> t'FT { REOUIREMENTt! r•, k: ; = P' — <br /> SAMPLE <br /> MEASUREMENTa <br /> r <br /> PERMIT <br /> REQUIREMENT �ryr r;:r x:. . ' j r t - .�• �• t i r <br /> SAMPLE FI , <br /> MEASUREMENT„ I ! <br /> PERMIT.. aes :' 1 .,s .`yq_�� �J } . t;' ` 4`• 4 " y, i' s { I , ' <br /> REQUIREMENT+; <br /> kra <br /> SAMPLE <br /> aJ MEASUREMENTS <br /> - PERMIT' '• ': "N .;$�:,J-' ,'^r.`,•. 1 'r•;c�,.,•.•?`., j - 1• - :.: swr d� ': •tw�.e. <br /> REQUIREMENT <br /> t ,a <br /> SAMPLE G i <br /> MEASUREMENT :: <br /> i <br /> PER ,. :, ''"r i wi:s" - �' _ r C Yi'• } ��4"j <br /> REQUTAEMENT :ti by•,t"�. t 9s: i M1';Y�i,,>~ °: jy (3, w� "s t" �y r' 'Rt C w s i`T' i. 1- <br /> SAMPLE r <br /> MEASUREMENT'- <br /> tj PERMIT...G «., rXx.••„ it;2ta�%_','r w.. �ti 79v <br /> REQUIREMENTS <br /> SAMPLE -✓�4; _ +7' <br /> MEASUREMENT- - 1 <br /> PERMIT .t. °' ".'a ', '+. 1 v ✓� F I <br /> REQUIR ;,,y,yy rM I w�� w :'t� ✓ it 4 ». s <br /> EM w ;1�,+y.'`.; ^,r%P`,d.°�K `:�,3`"�;t• t i,.t +s' �,t3 "' rf. *s .w t . <br /> NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE DATE <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN;AND BASED <br /> ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG- �. <br /> NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING <br /> _ THE POSSIBILITY OF FINE AND IMPRISONMENT.SEE 18 U.S.C. 1 1001 AND SIGNATURE OF PRINCIPAL ECUTIVE t; <br /> '~ 33 U.S.C. 4 1319. (Penalties under these staMla may include fines up to 110,000 ' <br /> A-- TYPEDORPRINTED and ormasimumLnprisonmentoJbetween6monthrandly fs.)_ OFFICER OR AUTHORIZED AGENT ! A i NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS(Reference all attachments here) <br /> OIL All CPO.ASE; .SCE FC07kNJ7AE P/:• ' 0--M'UST REPOPT It Ek._rMPTI'JNS CLAimin. TSS MOST bF >Gr.F RTE:1 AT ALI, <br /> TIMES. <br /> EPA Form 3320-1(Rev.9W Previous edltlons maybe used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF <br /> 4003t;/10a5�'9-17u1.� 2 <br />