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PERMITTEE NAME/ADDRESS (lnclyde Faci/iry Nmndlacadon ifDiffermr)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPOES) Form AppfoVed.
<br />DISCHARGE MONITORING REPORT (DMR~
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<br /> YEAR MO DAY YEAR MO DAY
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<br />PARAMETER 46-53 (54-61 395) 4E53) (5461 EX OF TYPE
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<br />NAME/TRLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF
<br />WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMTRED HERE NALLY E7UU11NED AND
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<br />AND BASED ON MY ' TELEPHONE DATE
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<br />h INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV S IMMEDIATELY RESPON
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<br />FORMATION IS TRUE,
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<br />970-870-271 p..
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<br />T'i,V ~YOT1 Mf±TltB~ i'~1; 1i ( PENALTIES FOR SUBMITTIN G FALSE INFORMATION, INCW
<br />NG THE ~ / ~ ~ ~/
<br />, POSSIBILRY OF FINE ANO IMPR ISONMENT. SEE 18 U.S.C. 4 1007 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
<br /> 4 1319. (PeMHiav under Nose sNturos may Include Hoer up ro f10,000 end or OFFICER OR AUTHORIZED AGENT
<br />TYPED OR PRINTED mWmum lmpdsanment pl aeMSenemonrhs end5yeers.) NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIULA I IONS (Hererance au eDecnmenrs oars)
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<br />EPA Form 3326.1 (08-85) Previous editions may not be used. (REPLACES EPA FORM 7-40 WHICH MAY NO7 BE USED.) ^ i ~ ,t ~ 7 ~ T r II I ^ _ 1 ~ , I PAGE OF
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