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PERMITTEE NAME;ADDRESS,hrrbrde Facilq;. NameL? arion if Diffe rno <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 />NOTE: Read <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br /> <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <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 />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certit% under pcnahy,mt law that this ducumcnt and all attachrmtnts acre TELEPHONE DATE <br /> prepared under m} direction or cupentsion in accordance wnh a svstcm d signed <br />-'" - to assure that qualified ret,onnel prnpcrly guheT and evaluate the information <br /> submimd Bawd on my mqutn of the Nmm or pcrMms who manage the,vstem. <br /> or those persona directly rcsponsthle for gather-mg, the ntlirmatmon. the information = <br />r submmcd is. to the hest of ma knowledge and behcl. true. accurate, and complete <br />/r r? - i - ' <br />SIGNATURE OF POINCIPAI FXFCIITIVF <br />- I _ ?:?7, _ <br />?! _ <br />TYPED OR PRINTED m Iodine ncposuhiliq of tine am! nnpnwn i .a i; . <br />'OMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO AY <br />Form Approved. <br />OMB No. 2040-0004 <br />before completing this form. <br />NO. FREDUENCY SAMPLE <br />EX OF TYPE <br />This l3 a 4-part fonn. PAGE OF