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PERMITTEE NAMEIADDRESS (Include Fa6lit Sarnelb cafiarl if Different/ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION 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 LYSIS <br />AN TYPE <br /> A <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <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 /> <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I verUf> under penalty of law that (his d.KVment and all attachments were TELEPHONE DATE <br /> prepared under my dinviinn or wperyi%ion in accnrdame with a srvtem designed <br /> to assure that qualified penonncl proprrly gather and evaluate the information <br /> vuhmitted. Rasrd an my inquiry of the perwn or prrumo-whn manage thr system. <br />or thrnr persons di-dy respunsible for gathering the information. the information - <br /> submitted i, to the best or my harm l dge and helief. true, accurate, and complete. <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that them arc oignil'i"m penalties for submitting rake information. AREA <br /> risrmmem rot Am,wing violmions. <br />ibilit <br />of r <br />d im <br />di <br />th <br />i <br />l OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED p <br />e lans <br />e <br />im an <br />nc <br />u <br />ng <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all affacnmenfs nere) <br />This is a 4-part lorm.