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RERMITTEE NAME/ADDRESS pnclude FaciGly NumeiCxmion j DifJerem) <br />NAME <br />IHAEF~r tIN1NC, S<vC. <br />ADDRESS <br />]}iAEr.`.F WINE <br />C.l.• ~. l.A 1'if <br />FACILITY C''A 1G CG 81ttb <br />LOCATION <br />A T9N_ .1_ ^rl~rfX [r7FFr C~~4r/CFA' if.A <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT (DMR~ OM8 No. 2040-0004 <br />Iz~tsl nr~ sl t I N C k Approval expires 0531-9R <br />''~'- ` )SEC'S ~Y) <br />PERMIT NUMBER DISCHARGE NUMBER r_ t I G f L I` i? A~ <br />MONITORING PERIOD E C n C A `_ 7 C N C t? t E C L l C n <br />YEAR MO DAY YEAR MO DAY __ <br />FROM GC C4 1 TO GC G` ~1 ."t hC CI'CdAFCE ! ~ etc <br />/zo-zq nz-z91 Iza-zsl rzs~zrl Iz~-z91 Wo-3,) NOTE: Read Instructions beta eZampletinq this form. <br /> (3 Cerd Ony) QUANTITY OR LOADING (<Card Only) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE <br />PARAMETER (4653) (54-61) (38-45) (46-53) (54-61) EX OF TYPE <br />(32-37) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />(s2~31 ANALYSIS <br />(64-68 <br />(69-70 <br />[i! SAMPLE ~:~=iS::r 4L~.',::':[~ ., ) 1.) <br />~ <br /> MEASUREMENT ~ G 8i~i f~ ~~~ <br />'L'4UU 1 0 C PEAMI7 ?0#t>'t7A #IPi#tX1 # ;';°:: 6.5 #rSr4>D*~+ •0 4 ENL9 Y$1SU <br />r'ELUEdT t;hC:;S YnLIiE RE[FIUIREMENT *. ~^Y E;INIC.UlS K YICC `_C <br /> SAMPLE <br /> MEASUREMENT <br /> . ' < T-, <br />., a <br /> REQ f M6D~ , <br /> SAMPLE <br /> MEASUREMENT <br /> :PERMIT <br /> FiEpU1R@MENT <br /> SAMPLE <br /> MEASUREMENT <br /> ,PERMIT <br /> AEOUIRGMENT ~ . <br /> SAMPLE <br /> MEASUREMENT <br /> r '.~ <br />P ~ <br /> k. .,,: <br /> SAMPLE <br /> MEASUREMENT <br /> <br />~.ry C to d <br /> <br />'~! ~ 1 kI <br /> I.E~ulEtfit' <br /> SAMPLE <br /> MEASUREMENT <br /> <br />-y'.- ~Fp <br />- <br />- sr,.. <br />- ~ <br />y <br />. . <br /> ,~~- AEMENT , t a ~ <br />_ <br />~, ~. <br />~ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTFY UNDER PENALTY OF <br />AM FAMILIAR WITH THE INFORM LAW THAT I <br />HAVE PERSO <br />ATION SUBMITTED HERE NALLY E%AMINED AND <br />IN; AND BASED ON MV TELEPHONE DATE <br />INQUIRY OF THOSE INDIVIDUAL <br />IO <br />R S IMMEDIATELY RESPONSIBLE FOR OBTAINING <br />D <br />I <br />M <br />O /7 <br />~--- <br />ACCURA E <br />AND <br />OMPLE~E~ <br />W <br />Gordon Peters PENALTIES FOR SUBMITTIN E AM AWARE <br />THA <br />T THERE <br />A E <br />SIGNIFICA T <br />G FALSE INFORMATION <br />INCLUDING THE ~C ~~ 970-924-4401 OU 0/ c'S <br />. <br />r i / (' a ~ POSSIBILITY OF FINE AND IMPR <br />§ 13t9 <br />Pe <br />nles <br />r th <br />e <br />tl , <br />ISONMEM. SEE 1B U.S.C. 5 1001 AND 33 U.S.C. <br />sretNes ma <br />i <br />l <br />tl <br />lu <br />E10 <br />000 <br />tl SIGNATURE OF PRINCIPAL EXECUTIVE <br />. ( <br />y <br />na <br />an <br />e <br />es <br />nc <br />u <br />e <br />res up ro <br />en <br />or <br />, <br />TYPED OR PRINTED maximum impnsonnrent of DOtxeen6monlrts entl5 years <br />) OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />MO <br />DAY <br />. ~ <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference a!/ attachments here) <br />'I5~ 1CI'AL IFCN L1C1".:, NILi. i'°: '~AI7EL', nhL Si:TLtFr!. :.C:.:~:_ LIt;'I i~k:;.;r:. I•_< C_It':r,:4Ei EC.1F EYEti- <br />;;L•e ;,;Lt.N CF ENCCF EE~,UILECENTE UNDen 1.R.3. FEIt:11:E rl,:;: i?nL rI1 +•:?`Ch,;.:E ,.,=L-!= ,. FtLLCE Lk <br />E` arm 3330=1 S- r wous edi ions may not a us (REP ~ ~ .QRMsT-40 RICH ~ AY O ~D.) ~ ~ - ' <br />I PAGE OF <br />