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PERMITTEE NAME/ADDRESS (Inclyde Fadliry Name/fayion ifDif(erorQ
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCNARGE MONITORING REPORT fDMR)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Fonn Approved.
<br />OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICenily under perWNMlaw Nat this document end en attachments were TELEPHONE DATE
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<br />e SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED I em aware that Here ere signRrant penalties for submitting talso iMOrmetion, OFFICER OR AUTHORIZED AGENT
<br />NUMBER
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<br /> Inclutlin the ossiblli er tine end im rlsonmant for krgwi Notations.
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
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