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PERMITTEE NAME/ADDRESS tlncladt hacif q .%amen,,rrttiun if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <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 /> <br />OF <br />SAMPLE <br /> EX SIS TYPE <br /> ANALY <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> <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 />NAM -ynTLE PRINCIPAL EXECUTIVE OFFICER I certify under penalt.or law that this document and all atuchnunt. were <br />prepared under m. direction or supenision in accordance with a %%%tem designed TELEPHONE DATE <br /> to r. Sure that qualified penonne'l properly gather and r1'almltr Illy inro-ation <br /> submitted. Bard on nl% inquir% of the per.on or per,suls who manage the system. <br /> or those persons diredls respurrable for gathering the infnrmaliun. the information <br /> submitted is. In the best of ms knowledge and hellrf. true. amurale. and complee. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that there are signircant penalties for submitting false inrormatiun. <br />wi <br />n <br />t f <br />r k <br />siolatio <br />s <br />h <br />fl <br />d i <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED no <br />onmrn <br />o <br />ng <br />n <br />. <br />including the possi <br />ilii% of <br />oe an <br />mpr <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />This is a 4-part torn.