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<br />ADDRESS T ~ A F 1' ;•; ? ~ T ' •.
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<br />NATIONAL PoLLUTMi DISCNMOE ELIMINATION SYSTEM llYf'~E$)
<br />DISCHARGE MONITORINQ REPORT /OMR/
<br />1-18/ a7-191
<br />~04 32115 X10? ~
<br />PERMIT NUMBER DISCHMOE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAY
<br />FROM - ~ ~ TO
<br />!16111 l11-131 (11.151 !1617/ l18-191 !36311
<br />Form Approved. -
<br />g r 9 ~ n OMB No. 2040-0004:.
<br />(S'[ n D ~I u) Approval expires 05-37-98 6',.
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<br />NOTE: Rud Mstruetlorr befan completing this lam. ;i
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<br />NAMElTTTLE PRINCIPAL EXECUTIVE OFFICER I cERnfr urlDm PENAIn of uw rNAi I NAVE PERSONALLr EXAMINED AND TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFORMATION SUBMITTED HEREIN; MD eASEO ON
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<br />MY INQUIRY OF THOSE INDIVIDVAL9 IMMEDIATELY RESPON9BLE fOP ,E
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<br />W OBTNNINO THE INFOMIATON, I BELIEVE THE SUBMITTED INFORMATION IS ~
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<br />L- 970-824-4401 ~9 J~ 2]
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<br />~ TRUE, ACCUMTE MD COMRETE. I ANI AWME THAT THERE ME
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<br />SIGNIFICMT PENALTIE] fOR SUSMITTINO FALSE INFORMATION
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<br />TYPED OR PRMITED ..edm.xlx.xn irEVi,pvnNlrorMO,wn enNemsrgsr....l OFFICER OR AUTHORgEO AGENT caDE NUMBER YEAR MO DAV
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