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YCrIMIYI Et NAME/A~ORESS (include Faci/Try NamdLocaMan if DiJferen0
<br />NAME
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<br />ADDRESST k A V P ~: C I •; ,i
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<br />FACILITY y ~~ A L' C 7 B 1 6 l 5
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDESJ
<br />DISCHARGE MONITORING REPORT (OMR)
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<br />.. PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAY
<br />FROM ;11 ~ ;) TO 7
<br />Form Approved.
<br />OMB No. 20x0-0004
<br />"INOH
<br />(SU3fi NM)
<br />F - FINAL `_IFn*
<br />PDV'1 IL5 TO NO NAM3 ~:ULCN
<br />.'. NOSE: Rea Instrudlons befo pleting this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
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<br />NAME/TITLE PRINCIP E%ECUTIVE OFFICER ICertiry under penalty oNawthat this document and all attachmems were TELEPHONE DATE
<br />
<br />.;. GOLdOn Petl1':: prepared under my diradion or supervision in eccortlanca with a system tleslgned
<br />to assure that qualified personnel properlygalherandevaluatetheimormalion
<br />submitted
<br />Basetl on ny inquiry of rile person or persons'who mana
<br />e the system
<br />~_
<br />G/L
<br />~ ~
<br />970-824-4401
<br />01
<br />C4
<br />26
<br />'resident/General Manager .
<br />g
<br />,
<br />orNOSepersonsdimdlyraeponslblabrgetheringlheWOrmatkm,iheinionnation ~
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<br /> submined Is , to the best of my knowledge and baliel, tma, accurate, end complete. SIGNATURE OF PRINCIPAL E%ECIJTIVE
<br />,•TYDED OR PRINTED I am aware that there em significant penalties for submitting lake information,
<br />inewdin the oss~bei of Ana antl im risonment for knowin violations. OFFICER OR AUTHORRED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />V V MMtrv I J AN V..IcAYLANA NON UY ANY VIULA I IUNS (lie/e2nCe a// attdCnmenl5 neBJ
<br />:~> ~ TJYAL IRON i.Il:ITS TILL i3S enIYED. AND SgTTLF:A?LE :;?LIDS LZ~ZT AFPLI~D FJH <=1GYH~24NR PRECIP EY88"'-
<br />••:r r)U4DE11 OF PRO'JF HE~UIkENENTS UNDEk 1. A. 3. PFR*ITTE> MUST TAKE ALL F.cASONA3LP MEASUe7ES TU REDU~c'. P)i
<br />OA For`m` -1 /9) revious e i ion may a use - " ~ ~ ~ 1 ~ 00 2 S 3 / N n 1171 THIS ISS ~-PART FORM PAGE OF
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