Laserfiche WebLink
PERMITTEE NAME/ADDRESS lfnrlude F'arilitr .~ilme/Location if Uifferenn <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />.~ ~if~4 <br />~i F~. ~~~i~a:~ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <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 />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N~• FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <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 certd. nndar L n.,it...n..., th:,i tln. diwumem and au auarhmrnl. wrrr TELEPHONE DATE <br /> prcparcl) unda•i m+ dirar~lu,n nr wla•n i+lun in ueaordnncc with a +..Irm dv+iynad <br /> lu a+surc Ihal quali6rd prnonnrl prvgrr rl. yalhrr and r. aluutr Ihr infurmaliun <br /> +uhmiuad. Ra+ed on my inquiry of lhr person or la•non. whu manage tlw ++.Irm. <br />nr lh,ne person. direclh n•.p,nnible fur Xalheriny the inform:uion. Iha• infnrmalion <br /> Ia• <br />l nl <br />. Anowl <br />d <br />r and M•licf <br />!na• <br />x~runatr <br />anA cwn <br />Aelr <br />b <br />iu <br />l i. <br />t <br />th <br />• I <br /> y <br />, <br />. <br />g <br />. <br />w <br />m <br />, <br />.. <br />e <br />, <br />m <br />y <br />. <br />a <br />a SIGNATURE OF PRINCIPAL EXECUTIVE ~ <br /> <br />I f am aware that the rr am riynirnvm prnaltie+ fnr whmiuink fal+r informali,nl. <br />ihili <br />ri+onment for Annwin <br />+iolaliurt+ <br />i <br />h <br />d fi <br />e a <br />d i <br />li <br />rt <br />OFFER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MQ <br />DAY <br />TYPED OR PR <br />NTED y <br />. <br />nc <br />a <br />ny <br />te pu.. <br />4 . <br />n <br />n <br />mp DE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form ss2o-t (Rev. 3,9s) Previous edi6or,s may be used ~ ~OOSt`• Tlti.-iti a 4-part fOnn. <br />