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PERMffTEE NAME/ADDRESS (/nclude Faciliry Nmrv/Localion i/Dijjerenq
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMfl~
<br />(2-161 (f T- 9)
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
<br />FAOM ' l-1 ~' I TO "rl "~
<br />(14211 !22-231 (24251 R&2]) (28-281 (3431)
<br />Form Approved.
<br />„ , , , , OMB No. 2040-0004
<br />Approval expires OS31-98
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<br />NOTE: Reed Instructions before compleling this form.
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<br />NAME/TTfLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WRH THE INFORM UW THAT I HAVE PERSONALLY E%AMINED AND
<br />ATION SUBMITTED HEREIN; AND BASED ON MY TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL S IMMEDIATELY RESPONSIBLE FOR OBTAINING ~
<br />
<br />Richard A4111,
<br />THE INFORMATION, I BELIEV
<br />E THE SUBMITTED INFORMATON IS TRUE, ~ ~ ,^
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<br />l ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT ~
<br />r!T //l//>' //G 970-870-2712 5 24
<br />anager
<br />Environmental ,1 PENALTIES FOP SUBMITTING FALSE INFORMATON, INCLUDING THE 99
<br /> POSSIBILITY OF FlNE AND IMPRISONMEM. SEE 1B U.S.C. 4 1001 AND 33 U.S.C.
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<br />' SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED az antler Naze afenrtaz may inclutle
<br />5 1318. (PanelO
<br />rnBJ up ~ 510.000 entl n
<br />melimum Impnsonmenr W befwaen 6months end 5 yevs.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
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<br />EPA Form 3320-1 (OR-95) Previous editions may not be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) „ ,I n ,t ., ~ ~ .I , ,I 1 3 - T s ,, I~ PAGE OF
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