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PERMITTEE NAME/ADDRESS (Include FacilUv Airme/l ocarion if Differeml <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 />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certify umlrr penaly or law that this dowument and all attachments were <br />Prepared under m) dinrtion (jr supenicion in am-dance with a system dt? igned TELEPHONE DATE <br /> w assure that qualified pre uiwl prupert) gather and eealuate the infornwtiun <br />submitted. Raced nn mr inquiry of the person or persons who manage the -tem. <br />or thou penum directly r t ponsihie fur gathering the information, the inrnrmatkm <br /> submitted is, to the 1-1 of ms knowledge and balk!. true, aavrale. and c,mtplete. SIGNATURE OF PRINCIPAL EXECUTIVE <br /> I am aware that them are signir"M penaltle for submitting false informatlcm. <br />A <br />EN AREA <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing s"wfi ms. OFFICER OR AUTHORIZED <br />G <br />T D NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />:+MIT A RF-WE <br />is C`: This is a 4-part fonn.