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PERMITTEE NAME/ADDRESS Unclud, Farilin :v'amdLocafion iJth)/ennf) <br />NAME <br />ADDRESS ^ :' L. E X <br />Ca 61639 <br />FACILITY COMF'E_EX <br />LOCATION l? CC) 61639 <br />' Wort r':T!`t .s t.ra .t T1<1•'1R: 0.tAAfA!?7~G7 <br />Form Apprgved. <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ((NPDES) OMB No. 0-0004 <br />DISCHARGE MONITORING REPORT (DMR) y` ;1 <br />-2UBR i <br />PERMIT NUMBER DISCHARGE NUMBER - FINAL 1-'•.l•IU <br />-:CHG TO TRIO/DRY CREEK <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO I I- NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ• FREQUENCY <br />OF SAMPLE <br /> <br />EX <br />S <br />S TYPE <br /> ANALY <br />I <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />1 <br /> MEASUREMENT <br /> <br /> PERMIT <br /> <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ?- _ <br /> PERMIT t .I- <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br />SAMPLE <br />/ <br />) <br />t / <br /> MEASUREMENT r <br />? Yr <br /> „ I. <br /> PERMIT ._ ... _ J <br /> REQUIREMENT <br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I "emirs under penalty of lam that this document and all attachments were TELEPHONE DATE <br /> Prrpand under my direction or utpenision in accordance with a system designed <br /> to assure that qualified per,onnel proprri% gather and evaluate the information ' <br /> submitted. Rased on mr inquire .?rthe {Kenn or persons who manage the system, <br /> or those persons dlrreth rc.ptn.ihlc for gathering the information, the information <br /> l w <br />b <br />l <br />t <br />d i <br /> cnenp <br />. <br />ief. 1-. accura <br />e, an <br />submitted is, to the hest of my kru.w -die and <br />e SIGNATUR OF PRINCIPAL EXECUTIVE ' - <br /> I am aware that there arr significant Penalties for submitting false information, AREA <br /> risonment for knowin <br />ddatioms <br />th <br />sibilhr <br />f fi <br />e a <br />d i <br />i <br />l <br />di OFFICERf OR AUTHORIZED AGENT NUMBER YEAR MO DAY <br />TYPED OR PRINTED . <br />e pos <br />n <br />n <br />mp <br />g <br />nc <br />u <br />o <br />ng <br />(;UMMLPIIQ MPeU CAr LMtIM 11%J1e yr M". •1v'Mlrvnsa l--crrn.c on ocwa.n.nc.na .sans s.? <br />POTENTIAL ANALYSIS BE <br />f Y k' C--' Q-ti'. J <br />EPA Form 3320-1 (Rev. 3139) Previous edtions may r.•e used TI13s'Is d4-part form.