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F ERMITTEE NAME/ADDRESS (InsiJr FwakiyNswa?Le arren (/p(Illeent) <br />NAME <br />ADDRESS <br />R <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTEM FNPOESf . <br />DISCHARGE MONITORING REPORT FDMM jJ <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 kwtructlom before complat" thlB form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. F"OUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT f - <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 />ME/TITLE PRINCIPAL EXECVME OFFICER t fe^IIr untler a"• q e law that this dorum,nl and all ellarh-tv were TELEPHONE DATE <br />prepared under m7 dlreellon or wprnNon I. accordance with a tralem dedgtwd <br />NA <br />to aewrt that 1ae11Bed personnel prgwly Lather and ..duet. the InftwwHllon - ' <br />. <br />rb-111trd. Bred on my Irpulrr of the prn or perto.r who menagt the sNtem, <br />or thine penas dlrecllt -P-milbke rw gathering the Inrormatim She Information <br />1 <br />- submitted h, to the bet of my knowledge and btMef, true, xsc mle• and compkle. <br />SIGNATURE OF MINCWAL EXECUTIVE <br /> 1 am aware that there ere slgnlfk l penalties for wbmltfing faba Information. AREA <br />TYPED OR PRINTED 1wheding the poadblul) of flm and Imprlsnrltn.nt for knowing .lolet>ons OFFICER OR AUTHORIZED AGENT CODE NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANA I IUn Ur nn r uwt.n r wrva <br />(Rev 3199) Previous editions may be used This is a 4-part form. PAGE OF