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PERMITTEE NAME/ADDRESS (Include Facility %mnr <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <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 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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT ..t . , ;.. r <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this dwinnent and all attachment were <br /> <br />? <br />TELEPHONE <br />DATE <br /> e with a system designed <br />I)mpared under my direction or supersision in arcordam <br /> to assure that qualified personnel properfy gather and esaluate the information <br /> submitted. Based on my inquiry of the person or Person, who manage the system. <br /> or those persons directly r-pnisible for gathering the information, the information - <br /> submiued is, to the best of my knowledge and belief. trite, accuntr, and compkir. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br /> <br />TYPED OR PRINTED <br />F lam aware that there arc signirwant penallie, Lir submitting fake information. <br /> <br />including the possibility of fine and impriwinment b-r knowing tiofalions. OFFICER OR AUTHORIZED AGENT AREA <br /> <br />NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />;ai.?F:57 <br />This is a 4-part form.