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PrHMITTEE NAME/AUUHL55 ilnclude Facilnp.Vamelocafion IJDifjeretul <br />NAME <br />ADDRESS <br />BOX 670 <br />EN CO 81639 <br />FACILITY MlI" n COMPi EY <br />LOCATION ;EN Q 8163"? <br />U,&rri1. Ft1=T'I AS4A-r7nK1 MANAC-1F=R <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form APPjjved. M <br />OME No. 2040-0004 <br />MINOR <br />(SUBR JC <br />F - FINAI <br />DSCHG TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX S TYPE <br /> ANALYSI <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT ,' t I <br />` <br />- <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE 1 I ' <br />1 <br /> RE <br />ENT <br /> MEASU <br />M <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE I' <br /> MEASUREMENT j <br /> <br />PERMIT 7 7 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />!~ r' <br />I I b J <br />(/ <br />(- <br />1--?' <br /> PERMIT <br />{ <br /> REQUIREMENT <br /> SAMPLE <br />3 <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT 1 <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certiry under penuhy of mw that IN, d,Kumeni and all altachmrnls were <br />repared under my direction or supers kwti in aevordance with a s-trm designed /1 TELEPHONE DATE <br /> p <br /> to a Burr that qualified personnel proprrls gather and e%Wunle the information <br /> suhmitted. Bawd on my inquiry of the person or penons who manage the ..stem. <br /> or those prams directly responsible fnr gathering the infurniusti,n, the information <br /> submitted k, to the best of my kw-ledge and belief, true. accurate. and complete. SIGNATU E OF PRINCIPAL EXECUTIVE I I <br /> <br />TYPED OR PRINTED I um aware that there are significant Penalties for submitting false information, <br />Including the possihdity of ram and imprisonment for knowing %Watiom <br />OFFIC R OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENIS ANU rAYLANAI IVN Ur ANT VIOLA I IUtrA (rrtIltUteetUtr an auawntrarna rrer e/ <br />WED FOR -lOYR.24HR PRECIP EVENT SUBJECT OF BURDEN <br />ION I TOR I NG - 1. B. 2, <br />EPA Form 3320.1 (Rev. 3/99) Previous eddions may be used.