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<br />PERMITTEE NAME/ADDRESS (Include Facl!!ty Nmne//geadon ifOBercm)
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<br />ADDRESSh7Ft=., ~_~?: ^'1 :.-~ C1M1'~ T't{
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<br />FACILITY
<br />LOCATION
<br />NATONAL POLLUTANT DISCHARGE ELIMINATON SYSTEM (NPOES)
<br />DISCHARGE MONITORING REPORT (DMR;
<br />(146) (I)- 9)
<br />'»')?715n '1~T+
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM -! TO '"
<br />11OZ1) (11-13) (1415) (1811) (1819) (JOJt)
<br />Form Approved.
<br />. 1 ., •. OMB No. 2040-0004
<br />Approval expires 051-98
<br />°T.. 7 1`Clka M Tn Crc.) r• •.~~
<br />NOTE: Read Instructions be} comp{sting this forth.
<br /> (3 Cent Onty) QUANTITY OR LOADING (4 Cent Onty) QUANTITY OR CONCENTRATION NO. FREOUEN SAMPLE
<br />PARAMETER 46-53 (54-61 38-45) (46-53 (59-61 EX OF TYPE
<br />(323n AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ,waLrsls
<br /> rezm) 89-68 69-70
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<br /> MEASUREMENT
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF L
<br />AM FAMILIAR WITH THE INFORM AW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
<br />IN
<br />AND BASED ON MY TELEPHONE DATE
<br />
<br />Richard :~?ills INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION
<br />I BELIEV ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE /
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<br />tnvlrorrmental t4a~TanT:r ,
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING ,
<br />I AM AWARE THAT THERE AAE SIGNIFlCANT
<br />FALSE INFORMATON
<br />INCLUDING THE ,f/ 970-870-2712 ~ ~~ ^
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<br />POSSIBILITY OF FINE AND IMPRI
<br />1319
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<br />SONMENT. SEE 70 U.S.C. 4 1001 AND 33 U.S.C.
<br />SIGNATURE OF PRINCIPAL E%ECUTIVE /7
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<br />TYPED OR PRINTED maximum ~mpnsonmer9 W SeMeen fimmW ends 1mrs.) OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
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<br />EPA Form 3320.7 (OB-95) rPrevious editions may not be used. (REPLACES EPA FORM 7-40 WHICH MAY NOT BE USED.) ~ ,~ T t 4 ~ a ~ „,t , ,,_ ~ ~ ~ rt PAGE , OF
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