Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Include FaciGryName/location if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 />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 <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I cerhf> under la•nulh of law that this, document and all altachment. were TELEPHONE DATE <br /> Prepared under my direction or caper. pion in accordance with a stem d-igmd <br /> to a-urr that qualified pennnnel properi} Rather and es,ahwte the information <br />%uhmilted. Bawd on m% inquire td the pt•nnn or pt•non% who mmnalte the system, <br /> or Its- penon, dirmlih '-prmsibls, (sit gathering the information. the information <br /> %ubmitl d is,, to the lxvl of m? knowledgi, and helirr. tom, accurate. and tYanplrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I am aware that there are %igniricanl lrenaltie. for %uhmit8ng false information. <br />including the 1-ihiliq of fins, and imprisonment for knowing Iiolation.. OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />/-,-This is a 4-part fonn.