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PERMITTEE NAMEIADDRESS (Include Fociliry Name/Location iJUifferent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />.-is tii 1 I ?L :. ?ai'.r' `? r•. YEAR MO DAY YEAR MO DAY <br />LOCATION EPA! CO 81t FROM TO <br />KeP 1. iir=r'I AMATTnN MAtvAMT <br />Form repNr?oved <br />OMB N,1040-00041P <br />F - FINAL <br />USCHG TO 'TRIB/]FISH CREEI <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE U t / <br /> <br />MEASUREMENT V <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE j• ( <br />L <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />?_ <br /> MEASUREMENT . <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />`` 1 <br /> MEASUREMENT L^ I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ! <br /> MEASUREMENT -- <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT OI 'i V <br /> PERMIT _ <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certifv under penah% of law that this document and all atimitmenLs acre <br />tio <br />isio <br />s <br />stem d <br />si <br />ed <br />de <br />di <br />o <br />r <br />i <br />ccordance with <br />ned r. TELEPHONE DATE <br /> y <br />g <br />prepar <br />un <br />r my <br />rec <br />r wp <br />n <br />n <br />n a <br />a <br />e <br />n <br /> to assure that qualified personnel properly gather and rsaluate the Information <br />submitted. Based on my inquin of the person or Persons who manage the system, <br />w <br />- <br /> or those persons dimd% responsible for gathering the Information, the Information <br /> submitted is, to the best of my knowledge and heikf. true, accurate, and complete. <br />f <br />f <br />I <br />th <br />t th <br />irk <br />l <br />i <br />f <br />h <br />it <br />i <br />l <br />i <br />ti SIGNATUR OF PRINCIPAL EXECUTIVE ' <br /> <br /> <br />TYPED OR PRINTED am aware <br />ng <br />a <br />se <br />orma <br />on, <br />a <br />ere are sign <br />ant pena <br />t <br />es <br />or w <br />m <br />t <br />n <br />including the imprisonment for knowing siolations. <br />pocsihHity ofneeand im <br />OFFIC OR AUTHORIZED AGENT <br />AREA <br />?E NUMBER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EAF'LANAIIUN Ur ANY VIUL.AIIUN5 (marerence all affacnmenrs nere) <br />IRE( <br />EST A REASONABLE POT] <br />EPA Form 3320-1 (Rev. 3188) Previous editions may be used. 7004 5 /