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PERMITTEE NAME/ADDRESS(/wd.&ForaryM..WLo wi (fD(fe t) <br />NAME <br />ADDRESS <br />BOX 11.03 <br />IA 0 8142f <br />FACILITY <br />NO, LOCATION IA CO 814 ? <br />e A \e r, r A r'f ,n d T kt= M,^-O <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /NPDES/ <br />DISCHARGE MONITORING REPORT /DMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 20x0-0004 <br />M I NOR <br />(SUBR MH ) <br />F - FINAL DE <br />SR, DEER TRI_ '> r i;i I B <br />NOTE: Read Instructions before completing this form" <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX couENCr <br />OF <br />r SAMPLE <br /> <br />TYPE <br /> ^NALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT _, a :• :.. <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 /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I `roily r pen. ty o law that thh document and att attachment, were <br />TELEPHONE <br />DATE <br />prtparrd under my direcllon or wper+tfon In accordance .tlh ..yetem dtstgtxd <br />to a " that 9-11rW personnel propeAy Bother and eraluale the Inror,nellon <br />eabmllted. Based on me Inquiry o (Ow person or person who manage tin rrstem, - <br />or Ihoee pereot" directly reeponsibfe ror gathering the Inrormatloe, the lnroe,n.uon . <br />eubmtlled b, to the bee( of my tnewkdgt and better. Irne, acv%irste. and complete. <br />9IONATURE OF PRINCIPAL EXECUTIVE <br />f L <br /> I am a.are that there are dgnl <br />lcan( Penaltite for mbmlttint rain Information, <br />TYPED OR PRINTED Inchtdl.g the possibility of floe and ImpAsoament for knn.ing Ool&Ub OFFICER OR AUT14ORIZEO AGENT CoOE NUNWR YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference DIM attachments herel <br />:r! <br />EPA Form 3320-1 IRev 3199) Previous editions may be used This is a 4-pan fonn. PAGE OF