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PERMITTEE NAMEIADDRESS (include Facility \amr/Lnarom if Ni(tenwr, <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 />0%413 No 2040 C ;il• <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />NQ, <br />FREQUENCY <br />OF <br />SAMPLE <br /> EX LYSIS <br />N TYPE <br /> A <br />A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE _ i "+ I / ?° T 1 <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -4 <br /> REQUIREMENT <br /> <br /> SAMPLE <br />J <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> „- .. <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE A <br /> MEASUREMENT ' <br /> PERMIT <br /> REQUIREMENT ',- <br /> SAMPLE <br />17 <br />II`I?-T <br /> MEASUREMENT <br /> <br />PERMIT <br />-. 77 <br />r <br /> REQUIREMENT <br /> SAMPLE C <br /> MEASUREMENT <br />PERMIT <br />1 F Ti <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 11-1i` under Penal ty of law that IIt i, dxumcnt ..it all wlachetents were TELEPHONE DATE <br />prepared under my dinrtion or sup-i%iun in ave-dance with a %},tm drsigned <br />that qualified prrwnnel properh gather and r•aluatr the informatkm <br />Nhhmitted. Baud on m• inquin of the rN`rM,n or Iha•rshm? who manage the <r elem. / -rte--- <br />or th,wa persons die-th re rm-ihle rnr gathering the infi,rmation. the informatun <br />It itted is, to the best 4 m? knowledge and he•lief. Irue. accurate, and chanplrte. SIGNATURE OF PRINCIPAL EXECUTIVE <br />in <br />C I um aware that tht r, are signirheant prnaltke far cuhmitting false information. <br />D <br />NT <br />AR <br />A <br /> tinlatiun% <br />ent for knowin <br />f fi <br />d i <br />6o <br />l <br />d <br />th <br />ih OFFICER OR AUTHORIZE <br />AGE E <br />NUMBER YEAR MO DAY <br />TYPED OR PRINTED g <br />. <br />e poa <br />ne an <br />mpr <br />am <br />trie <br />u <br />ing <br />nib - <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all anacnmenfs here) <br /> <br />00.- This is. a 4-part form.