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A' <br />PERMITTEE NAME/ADDRESS Qnclude FaNliry Name/LOCarian tfDBerenq <br />NAME _ _ _ -- _ <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMq; <br />(816) (1,- 9) <br />-. PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM 0 0 07 0 TO ~ :! 0 <br />(I6t1) (~~-Z3) (Z4-251 (~6-211 (29-29) (J631) <br />•IROR <br />- FIYSI <br />~'% OF Sc+/MINE <br />Form Approved. <br />OMB No. 2040-0004 f , <br />Approval expires O5-31-98'q ; <br />nEL,~M( <br />~~1' S <br /> <br />ADDRESSRC.I [ t Nr). :~ (N <br />P.O. i'J'i It 'S i <br />FACILRY PA(InIA CO 91429 <br />LOCATIONd O W : c <br />CO <br />B1u2H <br />4TTN: NILLT A7 ~. °1G 1]_ MT NP MGD <br />~ NOTE: Read Instructions betor~~bRfpleting this form. <br /> (3 Card Ony) QUANTITY OR LOADING (4 Card Ony) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER 46-53) (54-61 38-45) (46-53) 54-61) ~( OF TYPE <br />(32717 AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (sera) (~ 66Js 69-~0 <br />OZL AYD GItP.ASc SAMPLE a~sa6a ( 9M1) fia?i<'••`° ##i~#ca a#~,e^ <br />VISUAL MEASUREMENT <br />54066 1 0 0 ~ <br /> <br />n_:pfgMlT <br /> <br />~ <br />~ t <br /> <br />~r <br /> <br />~s-1 <br />• - ". IM ~ ~#IIt ,'tr ; ~ 3#'- <br /> <br />~ ~ ~ <br /> <br /> <br />~ <br />r.FFLUEMS GROSS YALU ~ RE ~ <br />~, T <br />M=. = r. =0 ~g , 1I~" ~ ia`:' 1~ ~' <br />;. " <br /> SAMPLE - <br />- ~ -~ <br /> MEASUREMENT ~ <br />~ - <br /> If ' a'c { A"' <br /> . <br />~ t sy <br />I <br />. , <br /> t <br /> SAMPLE - <br /> MEASUREMENT I - <br /> PERMIT ,~{ <br />- <br />~ ^-.~ "~ `~` - <br /> REQUIREMENT -.: * ,1" a ~ VV - ~` :`~ <br /> SAMPLE <br /> MEASUREMENT V <br /> ~ ; <br />. - _ 4.~ <br /> AEQUIREMENT , <br />yy G <br /> SAMPLE <br /> MEASUREMENT ' <br /> PERMIT' <br />'~: ~ N.~,~.+ <br />p }.,:.-: ~ 3 ~ , <br /> REQUIREMENT ~ w„- r <br />`~. ,~.4r ~~;:•~• `• <br /> SAMPLE <br />• MEASUREMENT <br /> PERMIT - -- - --- ~ ~,,- - -~ - .- ~~ <br /> REQUIREMENT _ <br /> SAMPLE <br /> MEASUREMENT <br /> ' <br /> REQUIREMENT - ' t r' ~ ; - <br />•~ `: <br />NAMERITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />AM FAMILIAR Wm1 THE INFORM LAW THAT I HAVE PERSO <br />ATION SUBMrTTED HERE NALLY EXAMINED AND <br />IN <br />AND BASED ON MV TELEPHONE DATE <br /> INQUIRY OF THOSE INDIVIDUAL ; <br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br /> THE INFORMATION, I BELIEV E THE SUBMITTED INFORMATON IS TRUE, / <br />~ ~ <br />j- J ACCURATE AND COMPLETE. <br />BMRT I AM AWARE THAT THERE ARE SIGNIFlCANT <br />INCLUDING THE <br />I <br />F <br />RMATION /~ ~~ <br />~ (~J 1d ~-, <br />~( ~.% ' / ~ ~~~ .r ~ ~ PENALTIES FOR SU <br />IN <br />POSSIBILffY OF FlNE AND IMPR , <br />O FALSE <br />N <br />O <br />ISONMENT. SEE 18 U.S.C. 41001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL E7(ECUTNE ~/ ~ ~~ ~ -~~>~ <br /> <br />TYPED OR PRINTED 4 1319. (Penel(ies untler Nese s <br />menmum lmpnsonmerrt of beMSa mtu(es mry inclutle lines uP M 510,000 sntl d <br />n6monthv entl5years.) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (RB/Brenda all atfeCnmentS 119!8) <br />.,E'C'iLEABL£ SOLIDS Li?IIT APPLIES ONLY IF C=IOTR, 24HR P2FCiP EVFRT IS CLAIM°9. IF CLA-!! dPPAOVf'D FT ~'~`CD, <br />~'j 55 t; IRON LIMITS WTL1. NUT flE APPLIED TO R?PORTwD 11FASU orr PY,.S_e;ap T. Awl, or; ; FOr. BURDCN OF PHOUF <br />E ~ `orm` ¢o-i' - ~ Prewo s editio s t b • ( EP CES~E AY ~ S .) - ' ' • PAGE OF <br />OOOSIt/90312-1?)~ ? <br />