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PERMITTEE NAME/ADDRESS (/nclyde Faci(iry NandLOCadon yDigerenq
<br />NAME
<br />ADDRESS:.-: ' r :.: ` I t. is
<br />FACILITY - .4 I .: _ : r' i r, l l-.
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form ApprOVed.
<br />DISCNARGE MONITORING REPORT (DMR) OMB No. 2040-0004
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<br />PERMIT NUMBER DISCHARGE NUMBER ~. ` _ t _ ,~ A )
<br />MON{TORING PERIOD ' 7'~ } ° ; r - . :i t'.': b C ::: ?, '~' !` ; 7 . t' :i
<br />YEAR MO DAY YEAR MO DAY _
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<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br /> EX OF TYPE
<br />PARAMETER AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANAI-YSIs
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<br /> MEASUREMENT
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<br />NAMErTITLE PRINCIPAL EXECUTIVE OFFICER ICenilyuMer penelry of law that thle document end ell attachmema were TELEPHONE DATE
<br />prepared under my direction or auparvisian in eaordance with a system designed
<br />b assure that queliaed personnel pmpady gather end evaluate me inlormetlon /r
<br />W. GD:dun Peters submMSd. aesetlannVkpuiryoltheparsmorpanonavapmanagalhanyslem, t'_ ~ C , ~~[~.L- 970-824-4401 Oi 07 ZS
<br />President/General Nan BgCr amore pereone dlractly responsible br gathering the lydonneflon, the lnbrmetlon
<br />submitted ie,to me best or my Mnowledge antl belief,tNe, BCCUrffie, and complete. SIGNATURE OFP NCIPAL EXECUTIVE
<br />I Nn aware mm mere ere slgnlRCarn penalties for aubmiaing lake inbm,etion, OFFICER OR AUTHORIZED AGENT
<br />TYPED OR PRIMED Intludlna the oossibiliN Olfne end imonsonnrent brkrowind vlolabons. rune NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
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