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<br />NAME Tf: :'Pi .? _ _,
<br />ADDRESS I' f{ '. t' r' . ~ ^. _ r
<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHMOE EIJMINATON SYBTEM (NPDESI
<br />DISCHARGE MONITORING REP011T IDMR)
<br />11-16I 17-I91
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<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
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<br />NAMEJTITLE PRINCIPAL EXECUTIVE OFFICER I LERTI
<br />AM FA fY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND
<br />MILIM WITH THE INFORMATION SUBMITTED NERDN; AND BASED ON TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMWIATELY RESPONSIBLE FOR
<br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />W. Gordon Peters UE.
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<br />AND COMRETE. I AM AWARE
<br />HAT THERE NIE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
<br />INCLUDING .!~
<br />~ 970-824-4401 98 4 28
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<br />THE POSSIBWTY OF RNE AND IMPRISONMENT. SEE IB U.S.C. 1 1001 AND S3 iIONATURE OF MIRIgPAI EXECUTRIE
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<br />EPA Fwm 3320.1 108-961 Previous editians•mey be used. (REPIACE6 EPA FORM Td0 WHICH MAY NO 8 USE .) 0 0 t• C ~ / 9 7 12I 1 - 1 fi ^1 G PAGE iOF
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