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PERMI7TEE NAME/ADDRESS Nnclude Facilur:l'amr/Lx~a+ian iJfNJ)'rnrul <br />NAME ' ' i, L);J , .. <br />ADDRESS +`t 1 ~ ~ ~- <br />D ~ ~E +`• ~8 <br />~_A CO 8i <br />FACILITY HCiR T Z UN 1t'f i !'•' ~ ~~' <br />LOCATION _ ai ~ ~ 'g i <br />1_Ri~CE WRDE i1li~lE MNPIAGEFI <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />form Approved. <br />OMB No. 2040-0004 <br />t `~VLiK I'lii 7 <br />F - ~ I illfil~ <br />r;R°,i~I^!F TF31'~'r TPT13 TO Tt_jTTL.E' D <br /><~ <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE `- ~ <br />i • , MEASUREMENT <br /> PERMIT I •>-;.{ , ,-. _.~ ~ , ~. _ <br /> REQUIREMENT ' 3t)tzr~ . , . t%f=i 1 :. • ' x _ _. •' t <br /> SAMPLE <br /> MEASUREMENTI <br /> PERMIT .•zxiti:i: - ~ r: ~ZEY~`?T ,, '- -; {~:. <br /> REQUIREMENT ~~UA AVr~ <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .- ,: t ,~ :: _ ~ , n t- r IJ . , ! - L ~ ... _ ~ :.-;;_ <br /> REQUIREMENT ~L+I1f1 F;`/i:, ~ I' ~" <br /> SAMPLE <br /> MEASUREMENT <br />': PERMIT ,:.4. t' ~. t t;-t" . ~•;: - i"; • ~;r <br /> REQUIREMENT _ • .; : f l_ ;" )- '";~ :: <br /> SAMPLE - <br />"_ i,-3L. MEASUREMENT <br /> PERMIT ih~• ''.r•tP 1 ? • .:; ~_~ .- . <br /> REQUIREMENT - '?!`+A A`i`r.: Dpi T 1. <br /> SAMPLE <br />.,.... MEASUREMENT <br /> PERMIT - I , .._ :~. 1- <br /> REQUIREMENT '~7DA AV(; ~ - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT _. .. .. - ... l ,.. ,- !: .- ~~~. :'"i•. .- <br /> REQUIREMENT _ " ~:+_~ IL1' ~1 :: :•I~. ; <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under prnalq of law that thh document and all utlarhmenl. were <br />d TELEPHONE DATE <br /> prepared miler m. dirrdirm ur wprnision lu wa,rdance with a .wtem <br />e+iRned - <br />- - -~_•. <br />` <br />~ to aseur that qualified prr.nmul prv.perl~ Italhrr and c,uluutr Ihr infurnmtlon <br />--'-'"- whmhtrd. Huw•d nn m~ inyuin of the penrm ur petxuis who mm~a>;r the c~aem. <br />h <br />f ~ ,, <br />' <br />-- r <br />- urmatlun <br />or thuu• pcMins diredl~ rop,nihle for gathering the infornwtfon, t <br />e In <br />t <br />d 6 <br />( <br />k <br />d <br />i <br />f <br />d <br />l _ ~ • <br />r <br />{ ~ ~ <br />`- <br />~ <br /> nuw <br />whmitt d ic• tr. the <br />iert of mr <br />r <br />ge an <br />c <br />M <br />, true. aecuratr, an <br />comp <br />ete. <br />f .. <br />- <br />~ <br />! L <br />SIGNATURE OF PRINCIPAL EXECUTIVE f <br />TYPED OR PRINTED I am aware that iherr arc ~i(piiricam penrltie. fur +uhmittinR fal.r in <br />ormation. <br />including the gntihilit. of tint and impri.onmem for Anowing .iolatinn+. OFFICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO <br />CODE DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />PAGE OF <br />B9) Prewous e~tlOrt6 may be used. = '~iib lY.~.~-dart 1.Ortn. <br />