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PERMITTEE NAME/ADDRESS lfncfude Faci4rt NamdLocation ifOiffrrrnll <br />NAME <br />ADDRESS <br />. BOX y70 <br />DEN fiq S1b39 <br />FACILITY _:rA MIME COMPL EX <br />LOCATION OEN :-D E31635' <br />f KARO, NECI-AiyiATIA7N I'lAP4AGER <br />Form Approved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) OMB No.J040.00N <br />DISCHARGE MONITORING REPORT (D R) nlrtp <br />r iv ) <br />PERMIT NUMBER DISCHARGE NUMBER - IAL ROL, <br />-L WET TESTING FOR 004A <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM <br />I I i - TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE I <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x •;: <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I eeraifc under penally of law that 11th dm< mrnt and ail atiaehmend were <br />prepared under my direction or wpery ision in accordance with a systern drei <br />nrtl <br /> <br />? <br />TELEPHONE <br />DATE <br /> g <br />to assure that qualifkd Per onnel properfs gather and eealuate the information ' <br /> whmitted. Rayed oft my inquiry of the per un or persons who manaW the system. <br />or those prnnny dinclh r?.pruts{hle for gathering the information, the {n!a"mation <br />f <br /> .uhmitted is. to the beq of my knowledge and helief <br />1n <br />arrurate <br />and complete. <br /> . <br />. <br />. <br />I am aware that 0wre are significant penaitks for whmitting false informalkm SIGN RE OF PRINCIPAL EXECUTIVE -' <br />TYPED OR PRINTED . <br />m, Ind{ng the poccihillty of fine anal imprhooment for knowing yiolntiom. OF ICER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATIVN VF ANY VIOLATIVNS (Reference aff affachments here) <br />ERIVATIONS AS "TOXIC <br />EPA Form 3920-1 (Rev. 3199) Previous eclitions may be used. TIl1 IS a'4-part fom1.