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PERMITTEE NAME/ADDRESS (/nclude Faclllry Nandlacarion YjDi$omq
<br />NAME 1:n~r..P. :!.[!~I%.;;, L-C.
<br />ADDRESS •• . ~ • ~ p r i, .. p .
<br />FACwTV `
<br />LOCATION
<br />
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (OMRf
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM ",U ~ TO ,1 ~.l:•
<br />Forth Approved.
<br />OMB No. 2040-0004
<br />. .: )~.
<br />NOTE: Read Instructions betore'completing this form.
<br /> QUANTITY OR LOADING QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER EX of TYPE
<br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS aNUYSIs
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER ICadily under penalty of law that shls document end ell enacnmerns were
<br />re
<br />ared under rt
<br />directlon or eu
<br />ervislon In accordance wAh a s
<br />stem desi
<br />ned TELEPHONE DATE
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<br />w. CaOIdOR Peters to nvure lMlqueliRed personnel properly gather end evaluate the lnbrtnNion
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<br />970-824-4401
<br />O1
<br />C7
<br />15
<br /> aubmRlad. 96aetl on rtry lnqulry of the person or persons who manage the system,
<br />t/General Mana
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<br />id or shoes persore directly responsible br gethering Nelnlortneaon, Ne lnbrtnatlan
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<br />res wbmiRed Is, to Ne best of my knowletlge end belies, true, accurate, end mmplete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED l em aware Nat there ere slgnfA;ant peneltlea for submlding lalse inbrtnatlon,
<br />Indutlin Ne sibil of (ne antl im risonmeM br Mnowin violations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />cUMMENTS AND tzrlarvn I lurv ur nrvr vlula I lurv~ [nererence au artacnmen[s here)
<br />,,~ E S~"FL IY._~d LI"STS :LL ±F ..;ld£i', .i).D `.'r.T'l.::;bL.`. :,~LIf;' LI".I° .4i'i'LI:i'"J: G=liY ,2cd4 F-?'iCI7 'V'-.'~-
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<br />EPA Form 3320.1 (RE / 9) Previous a Itions may be used` ~ ~ ~ '" ' T;11S ISTg4-PART FORM PAGE OF
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