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PERM?TTEE NAME/ADDRESS (Include Fetlliry Name/L«ation ijDiBeeenq
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<br />ADDRESSi~I'~'._ '..~3~;3 S^."^;~ ,C r:xAY PR
<br />FACILRY
<br />LOCATION
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) FOrtn AppfOVed.
<br />DISCHARGE MONITORING REPORT (OMR; w , OMB NO. 2040-0004
<br />(2-18) (11- 8) ? 7 ~
<br />' ~ ~ ~? ~ 1~~ rl i ~ a ~~ rt ~^ ~ L ~ Approval expires 05-31-98
<br />PERMIT NUMBER DISCHARGE NUMBER _ ci ., r T '"J:' TT
<br />MONITORING PERIOD +TN-- ~, ^nv~ ~• Tn v~7 ^. -t ^"~
<br />YEAR MO DAY YEAR MO DAY ~_ y
<br />FROM '~. ., TO : r ~ ... •: r,. ,.r ~(.yp„...~ ( t,.
<br />Raz1) (zz-z3) (ta-z5) (ze-zr) R9~z91 (~a31) NOTE: Read Instructions beforq.CO Rleting this form.
<br /> (3 Card OnN) QUANTITY OR LOADING (4 Card OnN) QUANTITY OR CONCENTRATION NO. FREOUENC SAMPLE
<br />PARAMETER (4G53) (54-61) 3845) (48-53) 54-87 P>( OF TYPE
<br />(32J7) AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANUY3JS
<br />69
<br />70
<br /> 161-d) 6468 -
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMIUAA WITH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY E%AMINED AND
<br />IN
<br />AND BASED ON MY
<br />~ % TELEPHONE DATE
<br />~(C)13 rd ~` i ~ ~ IS
<br />' INQUIRY OF THOSE INDIVIDUAL ;
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING ~~
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<br />~.l Y)YOnlTlentB) 115a ITa el-
<br />S THE INFORMATION, I BELIEV
<br />ACCURATE AND COMPLETE.
<br />PENALTIES FOR SUBMITTING E THE SUBMITTED INFORMATION IS TRUE,
<br />I AM AWARE THAT THERE ARE SIGNIFICANT
<br />FALSE INFORMATON
<br />INCLUDING THE
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<br />970-870-2712 r7
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<br /> POSSIBILITY OF FINE AND IMPRI
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<br />SONMENT. SEE 10 U.S.C.4 1001 AND 33 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE U
<br /> 4 1319. (
<br />eretties under mesa stetutea may Irlewde 5nes up ro 510,000 end or
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<br />NUMBER
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<br />EPA Form 3320-1 (08-95) Previous editions may not be used. (REPLACES EPA FORM 7-40 WHICH MAY NOT BE USED.) „,1 T n „ ~ ~ n ,., (t T ~_ T ~ n,I PAGE t OF
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