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PERMrME NAME/ADDRESS pttcbit iardey Naae?Lecatton l/D(Owwrs) <br />NAME <br />ADDRESS c <br />BOX 483 <br />NIA CO 81j <br />FACILITY I E NO. !-I T NE <br />LOCATION N I A C O 8 i. <br />1 TAM A G1=AA 10 MTAI{; MI <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM INPDES! <br />DISCHARGE MONITORING REPORT /O R! <br />PERMIT NUMBER DISCHARGE NUMSER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No. 2040-0004 <br />C S ?. <br />F - i IvAI i)L <br />SR; LIFER i-R! UTC: Of' VIvr:J TRIB <br />NOTE: Read Irnstructlone before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT s - . <br /> REQUIREMENT F1 X <br />('Hirt <br />!" <br /> I <br />t <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT #df at :, ;i ;y..; <br /> REQUIREMENT r!i?: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT N• F_ ! a <br /> REQUIREMENT Mf]t:, rya <br /> SAMPLE <br />tr _ MEASUREMENT <br /> PERMIT It IFS#? n.? C(: Tlr ,_ <br /> REQUIREMENT Al'G DA lI CfF 1"ICii 1TH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .,. j <br /> REQUIREMENT :N;T MAX C- <br />ONL'!-11 1 SAMPLE ?F# i?# <br />m'ENT r,l MEASUREMENT <br /> PERMIT REPO!-` '2EPORT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />- <br /> <br />PERMIT 1, j? ±i ... !? ,_• K.•; s - tt 3t i <br />.. i- -r A <br />7 TrT <br />REQUIREMENT r.Ic> <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ' ct11r " r,der Penalty 1.w that lhh document and all lt.cnmenu were TELEPHONE DATE <br />prepared ttnMr my direction or suP-blon In accordance with a system designed <br />to i ssum that qualified personnel Property Lather and evaluate the Information <br />submitted. lased on my Inqulry *(the person or persons who marnate the system, <br />or those perfo•e directly mpotdble for talhertag the Informatiow, the information <br />^ <br />submitted K to The best or my knowledge and belief. Inc, accurate, and complete. - - <br />l th <br />si <br />N6cant <br />lti <br />f <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />I <br />m awar <br />th <br />n <br />b <br />lln <br />r <br />t <br />Inror <br />ti -- <br /> g <br />Pe <br />a <br />e <br />e <br />ere am <br />a <br />es <br />or aa <br />m <br />ng <br />a <br />er <br />ma <br />on. t <br />TYPED OR PRINTED Including the possibility of fires and Imprlspnment W knowing violalio•m , <br />OFFICER OR AUTHORIZED AGENT _ <br />CODE NUMSER YEAR MO DAY <br />COMMENTS- AND EXPLANATION OF ANY VIOLATIONS /Reference eN ettechments here! <br />APPROVE'P ''v <br />3URDEN t!. <br />EPA Form 33201 (Rev 3'99) Previous editions may be used This IS 3 4-earl form. PAGE OF