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PERMITTEE NAMEJADDRESS pnclude Facilip~Name/Locarion fDiBerenQ <br />NAME PC4IE RESCUGCE' iICITEC <br />ADDRESS80ir1E N0. 2 TfIlE <br />P.G. nC% 4E3 <br />FACILITY FACNIA CO E1U28 <br />LOCATIOµJGNIE CC 81428 <br />ATTK: a1LLIAh A. 6E~F JR., l7INE EGA <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) FOfm AppfOVed. <br />DISCHARGE MONITORING REPORT (DMR; OMB No. 2040-0004 <br />a-.6, nr-9, CINCH <br />7 Approval expires 0537-96 k_;~ . <br />(SUER iC) <br />PERMIT NUMBER DISCHARGE NUMSER f- F I 11 ! I C E I ~~yl, <br />MONITORING PERIOD G W T E T C C E E F. T E S 11 L 14 C R ' <br />YEAR MO DAY YEAR MO DAY __ .~ (,i <br />FROM TO OC E 3C ~ ~ NC CI°CRARCE ~__~ ',~: <br />rzo-zlJ Rz~za1 rz~zsJ rz~zrl (za~zs, (3oa11 + .NOTE: Read Instructions before completing this form. , <br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (16-53J (54-61) (38<5) (46-53) (54-61 EJ( OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~'v'~s <br />0 <br /> (szc3, (ba-68 6&7 <br />COLIFGR!!, FECAL SAMPLE ~~~^vr ~~~=r+ +x~==~+ ( ] <br />-) <br />GENERAL MEASUREMENT Nr~ _ ~) f2. <br />7 4 U S S 1 0 G ''~ <br />~ ~ MIT ` Ix' ,~ ~ ,` x : # t~R#aIFA1 sk <br /> <br />` ~, °. <br />,. <br />.~ •~ / ~~r <br /> <br />EFELUENT GROSS irALU _ <br />H ENT <br />- ~~. ,:,~ <br />*,_' _; ~;t. <br />~4TY <br />~ <br />,", :"_~ 'e° ,~ <br />u , <br /> <br /> <br />Y <br /> <br />1 ! <br />L AND GAEASE S PLE ~~~~~ ( 94) ~m~~.~ ~+':#3+ +:~.:. <br />~ <br />S U A L MEASUREMENT UL ~ <br />84066 1 0 C ~_ ; ~ ~3 E5=1 ~ ~• ~2t <br />EFFLUENT GROSS YALU I 't' '~ -~~ <br /> <br />,. <br />~ <br />~' <br />x .. r . <br /> <br />,_ ~ . . <br />T. <br /> SAMPLE <br /> MFASUREM~N7 <br /> i yl ~` 4 <br />p t <br />L~'i <br />~ i:F <br /> R DiR '.5 <br />F 1 <br />ti <br />(~ d <br />` <br /> <br />f SAMPLE <br /> MEASUREMENT <br />`' ?HERMIT' <br />~ r.. ,I yt K ~ ` <br />~ <br /> RE4UIREMENT ~ )„':~~ ~ ~`= r =`~*_ ~ <br />~ ,' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ~~ ~ <br />` _ <br />_ ~ <br />I , <br /> REQUIREMENT ~r . <br />: ' <br /> SAMPLE <br /> MEASUREMENT <br /> r <br />e <br />~ ~ <br />~'~ <br />i <br /> ;jjEQU1REMENT ~ ;v,. '~ ~q <br />' " <br />, <br />' ~ ~~'~ <br />~ <br />~ °~ 4k '~ •a . <br /> . <br />T x1v~ . <br />, : r. <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> ?'i ;.PERMIT i ~- rA: • '$'r 5~"c ~7i i 'M'' .• 3 d ~t .~ ~ s<~ . <br /> I#E UIREMEN7 ~ :,. <br />. ~~ ± .~ . `.,x P~ $~.a3'"tr;' 1~ <br />.x <br />!` .a~" ,'^ `` <br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E7UMINED AND TELEPHONE DATE <br /> AM FAMILIAR WITH THE INFORM ATION SUBMITTED HEREIN; AND BASED ON MY <br /> <br />I /~ <br />~ <br />~ ~ ~ INQUIRY OF THOSE INDNIDUAL <br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />E THE SUBMNTED INFORMATION IS TRUE <br />~7 <br />~ <br />w r <br />ACCURATE AND COMPLETE. <br />PEN4LTIES FOR SUBMITTIN , <br />I AM AWARE ltiAT THERE ARE SIGNIFICANT <br />G FALSE INFORMATION <br />INCLUDING THE <br /> POSSIBILRY OF FINE AND IMPRI <br />§ 1318 <br />PoMaiec <br />th <br />d , <br />$ONMEM. SEE 18 U.S.C. § 1001 AND 33 U.S.C. <br />l <br />l <br />i <br />G <br />! <br />f <br />tl <br />b f <br />0 <br />000 <br />tl SIGNATURE OF PRINCIPAL EXECUTIVE ~ K ~~s S <br /> <br />TYPED OR PRINTED . ( <br />un <br />eca s <br />a9 may <br />n <br />ma up <br />an <br />o/ <br />a <br />Y <br />U <br />a <br />1 <br />, <br />w <br />mar/mum lmprlswMlenf of beAVeen6mortths and5yeers.) OFFICER OR 4UTHORIZED AGENT <br />NUMBER <br />YEAR <br />O <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Heterence ell attacnmants Here) <br />nEPURT "NCT" (NC CHICFINE TREATl±T) IF AO CRICRIAF USEC--SFE G/. OlI E GRFASE - 7.E.1.C, FG. E. (F1F1Y <br />~Ai'1FLING 1NSTfiUC1IGN~-I.C.6, PG. 9. <br />EPA Form 3320.1 (0&95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT 8E USED.) C 0 0 C 8 / 3 i C 71 E -1 ` 18 PAGE ` OF <br />