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ffRMITTEE NAME/ADDRESS pna.rF.edtyx..?tw oel-(/nfpD....r) <br />NAME <br />ADORESS <br />?I STATE HIGHWAY' !? <br />MEEKER ? ?' CO 81 <br />FACILITY "1 I NE <br />Loa?T1DN ^KEF? CO 81 <br />=1 I V T cA1nITl=r7 C: t Ia n•c nor- <br />NATIONAL POLLUTANT 04SCHAAGE ELIMINATION SYSTEM /NPDESI <br />DISCHARGE MONITORING REPORT IDMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMS No 2040-0004 <br />I - INTERIM <br />USSARU POND 'TO WIL5 <br />D I SCHAROF <br />NOTE: Reed Imtructlom before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <br />EX of <br />P <br /> ANALYSIS TY <br />E <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE (p? h, i /?r? <br /> MEASUREMENT <br /> ^ - - <br />c PERMIT { :> I REPI?F! I <br /> REQUIREMENT <br />I' 01711, ?:: ----- - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQVIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />N ENTITLE PRINCIPAL E ECUTIVE OFFICER 1 ern'tr ° r pfn y e a. that NN do.vmfnl end al utachmenb .ere TELEPHONE DATE <br /> prfPted undrr mr dlrecllo,, In eccordence with a rftem ddtned <br />/I i?-Rn L that qualfld Penennel ?Mo"Ar talhend •ahlatf IM InrOrnutlen *we <br /> <br />eobmllt.d. sand on mY Inquiry of the Penes. or Pfnom .ho manate "w frtl?m , <br />J <br /> <br />_ <br />' i or thole Pnwa dlrectlr -P--- for tatherlnt the Inrormatln, <br />e the Informaton <br />f <br />e. v g' 'Y G <br />t aubmllld b, to Ihf beat of my tne.4dte and bfllef. Ime. acm-le, and mnry4le. <br /> 1 am awan that then are eltntlnM Penaltlee far eubmlldn <br />falx Information tSIONATURE Of ?RINCWAL EXECUTIVE <br /> t <br />, ARIA <br />TYPED OR PRINTED IrKi" the blur or Ilm and Imprisonment for rno+la Idallone <br />nt v?+ 7 t • OFFICER OR AUTHORIZED AGENT CODE NUMffER YEAR MO DAY <br />COMMENTS AND EAFLANA I wPl yr nn >r V IVLn I rvrva Inerorence an erracnmenrs nwel <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This 15 a 4-part COETn. PAGE OF