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)
Lead
SAMPLE
*******
******
******
******
*******
MEASUREMENT
1.5
SAMPLE
*******
*******
******
******
******
1/Year
Grab
REQUIREMENT
Daily Max
Manganese
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
3.0
SAMPLE
mg/l
Grab
*******
*******
*******
*******
1/Year
*******
Daily Max
REQUIREMENT
Mercury
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
0.01
SAMPLE
mg/l
*******
Grab
*******
*******
*******
*******
1/Year
Daily Max
REQUIREMENT
Nickel
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
3.0
SAMPLE
*******
Grab
*******
*******
*******
*******
1/Year
mg/l
Daily Max
REQUIREMENT
Selenium
SAMPLE
*******
*******
*******
*******
*******
MEASUREMENT
0.2
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
I
ATTACHMENTS 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 RESPONSIBLE FOR
SIGNATURE OF PRINCIPAL
GATHERING THE INFORMATION, THE INFORMATION SUBMITTED IS, TO THE BEST
OF MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND COMPLETE. I AM
EXECUTIVE
AREA
NUMBER
YEAR
MO
DAY
AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE
OFFICER OR AUTHORIZED
INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR
CODE
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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