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PERMITTEE NAME/ADDRESS (/nclude Faciliry Namr/Location if Di$erenQ <br />NAME SgyE:C'A CGAL CClFALY <br />ADDRESSD a A M E k D <br />il,IYUEH CO e1E39 <br />FACILITY <br />LOCATIOF~,I A Y b S F CO 81 E! U <br />ATTJI: v. 5UD L•~OMA, CE"ItHAI "ANAJtR <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR <br />(z,el n7-~s) FLFO H <br />OOC "" ~ (SUBH hi) <br />PERMIT NUMBER DISCHARGE NUMBER }_ F I a I j <br />Form Approved ~"~!% <br />OMB No. 2040-0004 <br />Approval expires OS-31-98~ <br />FGU7T <br />MONITORING PERIOD CI~C iiA FCF. 7C ;FIE/Fl~h CFFFk <br />Y~ M DAY YEAR MO DAY <br />OM TO UU ] ] ==~"~ bC C15CHAFCk ~__~ +~% <br />(za " ~) (2q.P5) !z6 27J (18-29J (303,) NOTE: Read Instructions beforB completing this form. <br /> (3 Cartl Ony) QUANTITY OR LOAD (4 Card Onry) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (46-53) (54-61) (3B-45) (4E53J (54-61J EX OF TYPE '. <br />(3237) AVERAGE MAXIMUM S MINIMUM AVERAGE MAXIMUM UNITS <br />lsac.3, ANALYSIS <br />(6a-68) <br />(69-70) <br />Fk SAMPLE =F C~v::3r AL+?fiA CC'v t'.~': ( i4 <br />' <br /> <br />MEASUREMENT <br />- ;~ ~ <br />~„ 6 S /} <br />~/ <br />+ (J <br />1~S <br />U4UU 1 U 1 PERMIT >a4 ~~ ~ ~'~` +:+~ q ~ . , ;I. 9• C A E/ A51T <br />kt'FLULRT GROSS YALUH REOUIF]EMENT R'~ <br />i#' ~ G! <br />il <br />l .L SF <br />fCI <br /> . t <br />~ <br />l I <br /> SAMPLE <br /> MEASUREMENT <br /> HERMIT - ,; ; <br /> <br />;f3E~(UiIiEMEt4T r <br />, <br /> SAMPLE <br /> MEASUREMENT <br /> PEpMt7 ~ '~. *t `~' <br /> AE4aUIREMENT ~', <br /> I <br /> SAMPLE <br /> MEASUREMENT <br /> ~:~~ PE~1MIt~ - <br /> '1tEC,1kJIREMENT '' <br /> r <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> fiECYLIIREFAENT r1 f, , <br /> SAMPLE <br /> MEASUREMENT <br /> RERMIT " <br />~ ~ . <br />~ <br />~ <br /> REOU1flEMENT ~ ~~'- ` <br />- <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT , <br /> REQUIREMENT 1~~t1`` ;.a,- <br />NAME/TITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND <br />AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN <br />AND BASED ON MV TELEPHONE DATE <br /> ; <br />INQUIRY OF THOSE INDNIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING <br /> THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS TRUE, <br /> ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT <br />PENALTIES FOR SUBMITTING FALSE INFORMATION <br />INCLUDING THE <br /> , <br /> POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S C. § 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPA ECUTIVE <br />TYPED OR PRINTED mavimum~~onmem ol6aMee n6 months enC yea Saes up ro 510,000 end or OFFICER OR AUTHORI D AGENT A NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference e/I attachments here) <br />i:,. LII`.!T PILL bE ^AIYED AMD SETT[EA3LE SC LIDS LIFIT APFLIEL` FCR <=lUYF+,2l[Ne FnEC1F EYE11~ 45~ E <br />i;C'FTL£AULE SOLIllS 11EIT WAIVED POH >lOfk,2YNR PAECIY EVEF:T SUBJECT TC LUh~cN L: F' FFCCF 7! I•A.i. C1L E <br />EPA Form 3320.1 (OB-95) Previous editions may not be usetl. (REP CES EPA FORM T-40 WHICH MAY NOT BE USED.) ~ ~ n ~ c • u n n a ~ ~ + < < ~ PAGE OF <br />