HAZARDOUS METALS - INLAND WATERS
STW / TXR05____________ / CO
PERMITTEE NAME/ADDRESS
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
NOTE: Enter your authorization number in the
(Include Facility Name/Location if Different)
DISCHARGE MONITORING REPORT (DMR)
underlined space in the upper right hand corner
NAME
(2-16)
(17-19)
of this page.
Example: STW/ TXR05J102/ CO
ADDRESS
N/A
PERMIT NUMBER
DISCHARGE NUMBER
Only If required, mail to: TCEQ (MC 213)
P.O. Box 13087
FACILITY
MONITORING PERIOD
Austin, TX 78711-3087
LOCATION
YEAR
MO
DAY
YEAR
MO
DAY
01
01
12
31
(20-21)
(22-23)
(24-25)
(26-27)
(28-29)
(30-31)
PARAMETER
(3 Card Only)
QUANTITY OR LOADING
(4 Card Only)
QUALITY OR CONCENTRATION
FREQUENCY
NO.
OF
SAMPLE
(32-37)
(46-53)
( 54-61)
(38-45)
(46-53)
(54-61)
EX
ANALYSIS
TYPE
AVERAGE
MAXIMUM
UNITS
MINIMUM
AVERAGE
MAXIMUM
UNITS
(62-63)
(64-68)
(69-70)
Arsenic
SAMPLE
*******
*******
******
******
*******
MEASUREMENT
0.3
SAMPLE
*******
*******
*******
******
******
1/Year
Grab
Daily Max
REQUIREMENT
Barium
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
4.0
SAMPLE
mg/l
*******
*******
*******
*******
*******
1/Year
Grab
Daily Max
REQUIREMENT
Cadmium
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
0.2
SAMPLE
mg/l
*******
*******
*******
*******
1/Year
Grab
*******
Daily Max
REQUIREMENT
Chromium
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
5.0
SAMPLE
*******
*******
*******
*******
*******
1/Year
Grab
mg/l
Daily Max
REQUIREMENT
Copper
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
2.0
SAMPLE
*******
mg/l
*******
*******
*******
*******
1/Year
Grab
Daily Max
REQUIREMENT
NAME/TITLE PRINCIPAL EXECUTIVE OFFICER
TELEPHONE
DATE
CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS
I
WERE PREPARED UNDER MY DIRECTION OR SUPERVISION IN ACCORDANCE WITH
A SYSTEM DESIGNED TO ASSURE THAT QUALIFIED PERSONNEL PROPERLY GATHER
AND EVALUATE THE INFORMATION SUBMITTED. BASED ON MY INQUIRY OF THE
PERSON OR PERSONS WHO MANAGE THE SYSTEM, OR THOSE PERSONS DIRECTLY
SIGNATURE OF PRINCIPAL
RESPONSIBLE FOR GATHERING THE INFORMATION, THE INFORMATION SUBMITTED
IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND
EXECUTIVE
COMPLETE.
I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR
AREA
NUMBER
YEAR
MO
DAY
SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND
OFFICER OR AUTHORIZED
CODE
IMPRISONMENT FOR KNOWING VIOLATIONS.
TYPED OR PRINTED
AGENT
COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
EPA Form 3320-1 (3-99)
(REPLACES EPA FORM T-40 WHICH MAY NOT BE USED)
PAGE
OF
Form Approved OMB No. 2040-004
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