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F'ERMITTEE NAME/ADDRESS mania& F.&,ryN?auo Lor.Hw ((D(fi aq) NATIONAL POLLUTANT OISCHAROE ELIMINATION SYSTEM IrNPOES/ <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS . <br />li O X 48-.PERMIT NUMBER DOSCMARGE NUMBER <br />N AON I A MONITORING PERIOD <br />FACILITY r''J I E PJQ. c NINE" YEAR MO DAY YEAR MO DAY <br />LOCATION ;NIA CO 81 i? FROM TO _ <br />:LLIAM A. DEAR JR. MINE M!: <br />Form Approved. <br />OMB No 2040-0004 <br />NOTE: Read Instruction, before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />CF MEASUREMENT <br /> PERMIT <br />,:-?-ic ;e -ir-. <br />:--K•k•ir - <br />K#,c -K;f•x <br />??.: . <br />,_:- <br />._• . <br /> REQUIREMENT SIN MP <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT >t##fF# i?sst`iitl 1GJ r##! x s oafs # _!.,,, <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT st####?t ###It# REPORT ##### ####?# rRL_Y OMP-: <br />LZL-D" REQUIREMENT SINGSAMP <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT #?###?t #ttiFiF## 100 #.# #+ttr#'## I ;. t'ltLY" <br /> REQUIREMENT MN VALUE <br /> SAMPLE <br />lliill?i fIC.11?7 ?•! f' MEASUREMENT <br />O O PERMIT t R }a;7Fi 1" <br />BELOW REQUIREMENT SIMG 5/41ji• <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,. _._.. REPORT <br />_:- .- _ <br />}-ti•:,r:. <br />=, ,<f. •_.i.;6; REQUIREMENT SINGSAt`f ' Ti " <br /> SAMPLE <br /> MEASUREMENT <br /> <br />.. <br />PERMIT REPORT 77 <br />REQUIREMENT S I NGSAMP <br />NAMERTTLE PRINCIPAL EXECUTIVE OFFICER t m n, y ° er pen. ty law that this dorumenl and all attachments wen TELEPHONE DATE <br />prepared under my dlr llon w suprrvltol n In accordance with • system designed <br />to aware that quallned personnel property, gather and evaluate the informatson , <br />submitted. Based on my Inqulry of the person or perwoo; who manage the "em, - - <br />or [how permo directly responsible for gathering the Infornnauon, the Infor,nation <br />< <br />nrbmllled M. to the bell of my knowledge and balk(. Irlee, Kvurvlo. and complete. <br />1 am aware that than on of rrnrenl <br />enalties for w <br />bmutl <br />SIONATURE OF PRINCWAL EXECUTIVE <br />rat <br />I <br />f <br />d r r", <br /> p <br />l <br />ng <br />e <br />n <br />o <br />on, REA <br />TYPED OR PRINTED lne+wlnE the po.+binty of flat and Imprisonment ror knowing .idadoem OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re%rence aN attachments hero) <br />_•c?T R'-SUET OF LETHAL TT" ?'FRT'lS A "%FFFECT", C=ROLJ H Aso' <br />TATISTICAL _ i?. i :-!f• F r:C!t. <br />_ ic:-rn:- - •r., ... .T-I-Ar'I-; -rny N. <br />r <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is, 3 4-pwA €Qrm. PAGE IOF