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PERMRTEE NAME/ADDRESS , I
<br />NAME ,_) ~ ,:. . ()elude Facil,y Name/Localion iJDlfferenl/
<br />ADDRESS' j+~ '. I r? S~ ' r n ...~~ r C^' N ~ it n o-
<br />FACILffY
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<br />NATIONAL POLLUTANT DISCHARGE ELMINATION SYSTEM MPDESI
<br />DISCHARGE MONITORING REPORT (OMR~
<br />(4-161 11 ]- H)
<br />., nn ~)'Y 7?511 r1nT e.
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORINR PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM .1 1 TO "' ''
<br />8641) R2-43) 8445) (764]1 Rssvl (3031)
<br />Forth Approved.
<br />„ ~ ~ „ ., OMB No. 2040-0004
<br />Approval e>~ires OS31-98
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<br />`NOTE: Read Instructions before completing this forth.
<br /> (3 Card On/y) QUANTITY OR LOADING (4 Card On y) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (46-53 (54-51 (38.45) (4f153) (5481) EX OF TYPE
<br />f37~~ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ~
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<br /> (54a31 6 70
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<br />NAME/TITLE PRINCIPAL IXECUTNE OFFICER I CERTIFY UNDER PENALTY OF l AW TMAT I HAVE PERSONALLY E%AMINED AND TELEPHONE DATE
<br />- AM FAMILIAR WITyi THE INFORM ATION SUBMITTED HEREIN; AND BASED ON MV
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<br />Ir
<br />' INQUIRY OF THOSE INONIDUAL
<br />THE INFORMATION
<br />I BELIEV S IMMEDIATELY RESPONSIBLE FOR OBTNNING
<br />E THE SUBMrf7ED INFORMATION IS TRUE '
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<br />ACCURA7E AND COMPLETE ,
<br />1 AM AWARE THAT THEAE ARE SIGNIFICANT ~
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<br />PENALTIES FOR SUBMITTING
<br />FALSE INFORMATION
<br />INCLUDING THE r i»r~ J
<br />970-870-2712
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<br />POSSIBILRV OF FINE AND IMPRI
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<br />SONMEN7. SEE 1B U.S.C. § 7001 AND 33 U.S.C.
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<br />GUMMENTS AND EXPLANAI IUN Ur ANY VIUTAI IONS (Hererence e0 enacnmenrs here/
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<br />EPA Form 3320.1 (ll$-95) Previous,ediUOns may not be used. r ~ (REPLACES EPA FORM T~0 WNICH MAY NOT BE USED.) n ,~ 1 ~ ~) ~ n ~ , rl ~ ~ _ (r ~ PAGE OF
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