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PERMITTEE NAME/ADDRESS rlnclude Facility .Namdlnealinn if Different) <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />ONIB No 2040-0004 <br />H <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />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 crrtifs under penalh of law that thi> daxnmrnt and all attachments were <br />di <br />li <br />f <br />d <br />d <br />• <br />i <br />i <br />d <br />i <br />h <br />d <br />d TELEPHONE DATE <br /> prepare <br />nn or sulw <br />un <br />amor w <br />a,"stem <br />erigne <br />un <br />er not <br />rec <br />r <br />s <br />n accur <br />t <br /> to assure that qualified pe-rine1 pfnfaerh gather and esaluale the inh,rmatirm <br /> h.hrnilled. Dialed on m% inyuin of the loor-n air persons wbo manage the system. <br /> or thou prrson+dwecll. responsible fnr gathering the informuligm, the information <br /> suhmilted is• In the lx<t of n% knowledge and belief. true, inmate, and complete. <br /> I am aware that there are si <br />niracanl <br />enalties fnr whmitting fakir information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED p <br />g <br />, <br />imluding the pwsibilili of fine and imprisonmrnl fnr knowing siodaflnm. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />ODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 33201 fRev 3/99) Previous editions may be used This is a 4-part form. PAGE OF