Spreadsheet: 133ff8bb-e9d1-4563-977f-acf61fa1a888
Sheet: Sheet1

Unnamed: 0 | CITY OF CARROLLTON | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11
 | ENVIRONMENTAL SERVICES DEPARTMENT
 | DISCHARGE MONITORING REPORT
FIRM NAME / PERMITEE |  |  |  |  |  |  |  |  |  | PERMIT NO.
FACILITY ADDRESS |  |  |  |  |  |  |  |  |  | SAMPLE DATE
NAME OF WASTE STREAM |  |  |  |  |  |  |  |  |  | SAMPLE TYPE
REPORTING PERIOD: From | /         /          to          /         /         . |  |  |  |  |  |  |  |  | SAMPLING TIME AND INTERVAL
POLLUTANT OR               POLLUTANT PROPERTY |  | CONCENTRATION (mg/L)  Permit Limit /  Lab Result |  |  |  |  |  |  | POLLUTANT OR               POLLUTANT PROPERTY |  | CONCENTRATION (mg/L)  Permit Limit /  Lab Result
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Name of laboratory conducting analyses
Name of personnel who collected samples
CERTIFIED STATEMENT: Pretreatment standards for this wastestream are        are not        being met on a consistent basis.
Additional operation and maintenance required to insure compliance is as follows or is attached
[NAME] daily wastewater flow | (gpd) |  |  |  |  |  |  |  | Avg daily wastewater flow | (gpd)
Avg daily production volume |  |  |  |  |  |  |  |  | Number of production days
AUTHORIZED REPRESENTATIVE CERTIFICATIONS:
A.  REPORT CERTIFICATION:  "I certify under penalty of law that this document and all 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 gathering the information,
the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.  I am aware that there are significant
penalities for submitting false information, including the possibility of fine and imprisonment for knowing violations."
 |  |  |  |  |  |  |  |  |  |  | Date
A.  Signature of authorized representative attesting to the Report Certification as shown above.
B.  TOXIC ORGANIC MANAGEMENT CERTIFICATION:  Applies only to industries subject to Total Toxic Organic (TTO) monitoring require-
ments and having an approved TTO management plan:  "Based on my inquiry of the person or persons directly responsible for managing
compliance with the permit limitation (or pretreatment standard) for total toxic organics (TTO), I certify that, to the best of my knowledge and
belief, no dumping of concentrated toxic organics into the wastewaters has occurred since filing of the last discharge monitoring report.  I
further certify that this facility is implementing the toxic organic management plan submitted to the permitting (or control) authority."
 |  |  |  |  |  |  |  |  |  |  | Date
B.  Signature of authorized representative attesting to the Toxic Organic Management Statement as shown above.
City of Carrollton, Environmental Health Department, 1945 Jackson Road, P.O. Box 110535, Carrollton, Texas, 75011-0535, (972) 466-3066.  March 2004.