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PERMITTEE NAME/ADDRESS(7m*.fo Fm4ka N.wa/Locd/ew(fD( 6-a). <br />NAME <br />ADDRESS <br />uHi-: / t.? <br />r-KER co E <br />FACILITY -UWY O M i N <br />LOCATION E ER C if E <br />=LLY D. ?ANUFR -; , VP OF OF <br />NATIONAL POLLUTANT DISCHAAGE ELIMINATION SYSTEM (INPDESJ <br />DISCHARGE MONITORING REPORT (DMRJ <br />PERMIT NUMBER aSCHAROE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />STREETEP GULCH TO GC;C-D GPGS CR <br />NOTE: Read btetruetlorw 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 r <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 /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />1 coati under pen. ty o few that this documrat and W attachments wen 1 TELEPHONE <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFICER <br />t <br />y <br />?7 DATE <br />prep-d under my direction or fuperr <br />oon In acc M.nrc with . system deigned <br />. <br />i 7th 77,1 / to anrun that queened per net proprrfr rather and evaluate the Inforrnatfon <br />submitted. Board on my Inquiry of the person or peraort, who "note the rntem. <br />or thorn peesoar direct), - po.wbl. for gathering the Inronnallow, the Inforuratlon <br />L? - 'l <br />ubndtted K to the bat of m <br />knowled <br />e and Wil.f <br />tru <br />a <br />conte <br />and co <br />kt <br />y <br />g <br />. <br />s <br />. <br />e. <br />t <br />mp <br />e. <br />SIGNATURE OF PRINCWAL EXECUTIVE <br />f <br /> I am .w.re that then an significant pe uild" <br />or rubmtttlng faire tnror natlon. A A <br />TYPED OR PRINTED IndWing the possibility of fine and Imprisonment for knowing vtot.uo OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS ANDEXPLANATIONOFANYVIOLATIONS /ReferenceeNattachments here] "R PRECI? EYENT tS CLAIMED IF CLAIM APP"iCIVED BY WQCD, <br />I . A. 2, " <br />C I* 10 <br />14 <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used (!?? t? `' -Th1d:YS;id 4-orl form. PAGE OF