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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDESJ FOfm AppfDVad.
<br />DISCHARGE MONITORING REPORT (OMR~ OMB No. 2040-0004
<br />rz-+e) nT. 0/ ° ~ • ~ ^ Approval expires 05-31-9R i
<br />'1^'177 iJ .11r ~ (crr^p •~qt1 i
<br />PERMR NUMBER DISCHARGE NUMBER r _ ^ " .~ /• • p ~ , • -, T I
<br />MONITORING PERIOD " r Y •' ' • "'r' n °•1 FnT n - 1 "' ^'"' 'd'`
<br />YEAR MO DAY YEAR MO DAY
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<br /> (3 Card Ony) QUANTITY OR LOADING (a Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (/6-53) 54-61) (38-45) 46-53 5<-61 p( OF TYPE
<br />(323^ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS
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<br />69-70
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<br />NAME/TITLE PRINCIPAL IXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />RH THE INFORM LAW THAT I HAVE PERS
<br />ATION SUBMITTED HER ONALLY E%AMINED AND TELEPHONE
<br />AND BASED ON MY
<br />EIN DATE
<br /> AM FAMILIAR W ; j
<br />
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<br />411 INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPONSIBLE FOP OBTAINING
<br />E THE SUBMITTED INFORMATON IS TRUE, ,.
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<br />1s ACCUMTE AND COMPLETE. 1 AM AWARE THAT THERE ARE SIGNIACANT ~
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<br />tal Nana er
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<br />E PENALTIES FOR SUBMITTIN G FALSE INFORMATION, INCLUDING THE
<br />~ 970-870-2712 5 24 99
<br />rolTmon
<br />nv POSSIBILRY OF FINE AND IMPR ISONMENT. SEE r0 U.S.C. 4 1001 AND 33 U.S.C. $IGNATURE OF PRINCIPAL E%ECUTIVE
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<br />TYPED OR PRINTED 4 13r0. (Penettles untler Hslse
<br />mer/mum impnarnmeM ar beMde siennes may Include fines uD b Sr0.000 entl w
<br />nEmorRAS end 5yesrs.) OFFICER OR AUTHORQED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLAI IONS (Rererence eu enecnmens oars)
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<br />Epp Form 3320.1 (DB-95) Previous editions may not be used. (REPLACES EPA FORM 7-40 WHICH MAY NOT BE USED.) ~ ~ } 1 ,l / N,1 ^ u ~ ,~-~ ~ ~ r PAGE OF
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