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PERMITTEE NAME/ADDRESS pnclude Facility Namebocarion ifDif(erenr)
<br />NAME IE'APPER ~~INI4Gr IN:'.
<br />ADDRESST~'AYP%R Ri I'E
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<br />FACILITY
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<br />NATX)NAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
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<br />PERMITNUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO OAY YEAR MO DAY
<br />FROM TO 1 v 3 3
<br />Forrn Approved.
<br />OMB No. 204P0004
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<br />(SJU3 NG)
<br />s - PI6AL
<br />DA": E'1 TO PLR GULCH
<br />NOTE: Read Instructions beforercompleting this form.
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRASION NO. FREOUEN SAMPLE
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<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANUrsis
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICertiy under penalty of la•x that this tlocument and all anachments warp
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<br />i TELEPHONE DATE
<br /> prepared under my direction or supervision
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<br /> to assure that gualifled personnel properly galherand evaluate the inlormatron ~ /
<br />GI. GOYdOII Petel9 submmetl. Based on my inquiryolthepersonorpersonswhomanagethesystem, ~ ( 970-824-4401 OL 04 26
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<br />President/General :Sana or those parsons directly responsible br gathering the iMonnation, the infomwtion
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<br />e best of my SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED 1 am aware that there ere signillcant penalties for submining false inlormanon,
<br />indudin the ossibili of floe antl im dsonment br knowin violations. OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence a!I attachments here)
<br />:i> TOTAL IRDH LIGITS PILL BF 6AIY°D, AND SE4TLCAPL'. SDLID5 LIMIT AYYLIcD £DR <=lOYR.2UHR PP.ECIP EYEpT-
<br />~EE 9URUEN DF 7RODF' kEQUIREBENTS UNDEii I.A.J. TDS (77NITDRING - I. o. 3. OIL 6 CREASE - SFE I. B. 1.(L).
<br />EPA Form 332 -1 / 9) revious a ttlons may be use ' T,(iIS IS A 4-PART FORM PAGE - OF ,
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