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PERMITTEE NAME/ADDRESSMod6iFar*IY)WO-WL caefaw((D(06r~) <br />NAME <br />ADDRESS <br />L i'' be 1` L) <br />1 ST(% . . r .." FiWAY i <br />FACILITY E3 <br />LOCATION` _?'WYO '• ? r• , <br />'-KER CO 8 <br />1 V rl QAKIr1L92t llo 19C no <br />NATIONAL POLLUTANT DISCHAROE ELIMINATION SYSTEM //NVPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISC14AA43E NUMBER <br />MONITORING PERIOD <br />YEAR DAY YEAR MO DAY <br />FROM - TO <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: Read Irvetructlons before ctimplr.thlp this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br />95 1 PERMIT <br />-PORT <br /> REQUIREMENT <br /> <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 /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMElTTE PRIN IPAL EXECUTIVE OFFICER e nn.ty u r pens y o Iw that Ihh 6-nwet and a4 ¦tiahna,tj wrn <br />TELEPHONE <br />re <br />red <br />nd <br />m <br />dl <br />lb <br />rM <br />l <br />i DATE <br />p <br />pa <br />u <br />er <br />n or sup <br />y <br />rec <br />s <br />on <br />n arcordante with .,J,tem designed <br />ri to amure that qu& fled Personnel property gather and evaluate the Information <br />- <br />tatbmltted. sated on my Inquiry of the person or pry who manage the sv,tem, / <br />/ <br />? or Iho,e persav dl retry rapoMble for ptheArtg the Informatiow• the information /?/ <br />?. <br />submHted h <br />to the heat of m <br />knowled <br />e and belief <br />t <br />u <br />a <br />vt <br />lr <br />a <br />d <br />l <br />t <br />? <br />G /? I V <br /> <br />l/ V <br />U <br />g <br />. <br />y <br />. <br />r <br />e, <br />tt <br />n <br />. <br />n <br />comp <br />e <br />e. <br />J <br />r <br />?- - l / •?? r I am ware Nat then an dgnllksnt penalths for rubmltting ralte information <br />SIGNATURE OF PRINCIPAL EXECU7WT <br /> , <br />TYPED OR PRINTED Inehding the possibility of fine and Imprisonment Im knowing vtolstiorm OFFICER OR AUTHORIZED AGENT COOP NUMBER YEAR MO OAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relorence aN attachments hare) <br />QED. ;.a aiJ'v'F't? <br />A 21 c. <br />EPA form 3320-1 (Rev 3+99) Previous ed+bons may be used 17) i 17 This is 3-4 0ati Corm. J' PAGE OF <br />. _ - I