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PERMITTEE NAME/ADDRESS (include fnci6y .YomdLn'afion if f ifferrnr <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 />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify under prnalty of law that this document and all attachments were <br />ared under my direction or suprnision in aet ordance with a.y.lrm dtsigned <br />re TELEPHONE DATE <br /> p <br />p <br />to :asure that yualtrtrd Personnel properly gather and evaluate the information <br /> submitted. Based on my inyuin of the person or persons who manage the system. <br /> or those persons directly responsible for gathering the information. the information ' <br /> submitted is. to the best of ms knowledge and Iw•lief. true. a urale. and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />' ' <br /> 1 am aware that them are signlrw'ant penalties for submitting false information. AREA <br /> violations <br />ibility of r <br />risunmrm for knowin <br />th <br />t <br />d im <br />i <br />l <br />di OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED p <br />g <br />. <br />e pws <br />an <br />an <br />nc <br />u <br />ng D <br />COMMENTS AND EXPLANATION OF ANY VIULA I IUNS (mererence an arracnmenfs nerej <br />OF PROI',F <br />This is a 4-part form.