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PERMITTEE NAME/ADDRESS (Include Facility Name/Location i(Different) <br />NAME <br />ADDRESS t }n n ' 3t__?'t t i "iif Jt <br />FACILITY , <br />LOCATION n• r- ,. r t a ?. •^ <br />c • .e.vi' .:.£t 'if' <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved. <br />DISCHARGE MONITORING REPORT DMR r. OMB No. 2040-000 <br />? ) <br />ry PERMIT NUMBER DISCHARGE NUMBER - • t- M f;a CY.' ; ? <br />MONITORING PERIOD`' <br />YEAR MO DAY YEAR MO DAY <br />FROM TO i; :fi ?r1 ?':i i ?i'•.`: t s";f <br />NOTE. Read Instructions befor completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY <br />OF SAMPLE <br /> TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br />• J ?. .... :.l _ ._ PERMIT <br />., ,•. '«: .Z(. <br />-.. f: :. ... "i: <br />YD'S. ZY <br />1.'l. «. <br />r <br />s . <br />s: <br />REQUIREMENT <br />i:...... <br />'>'; +' . i , <br />} <br />•t <br /> SAMPLE •.. :`: ..e . .. ,c J <br />)ryi_;? MEASUREMENT <br /> PERMIT iL n i •I': x n> rr+ .. s <br />•' ).. w?r,»?1"'. I yi"?.* t(+?i t i" REQUIREMENT _.:-•:.., 't '!"?; ? `, i';'?.?i• . `?-,'` <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />MT REQUIREMENT <br />tit SAMPLE 3i?rC. ,.'...ri.-. t•:c:;ii..;k .'•..•TiJ:'. ?ati? <br />TOTA <br />'• MEASUREMENT <br />, <br />. PERMIT <br />•?, •f n t; rr tc? zy €?? <.dL`' REQUIREMENT F <br /> SAMPLE ??'?-'d"?"• <br /> MEASUREMENT <br /> PERMIT k •t?l¢S5. t€ w• .. t s is .: '1 f <br /> <br />W-iLks- REQUIREMENT : s....: t <br />.:C< a £. fss ...+ a SAMPLE $ 01% -# ... <br />)rb ,a t; )r p..5 r a Ey,_ , MEASUREMENT <br /> PERMIT <br />% REQUIREMENT t ) ; <br />,t_ -r".ra _1 1 wi; SAMPLE c ..:? $ d .... Y t s r <br />3 L V MEASUREMENT <br />7 PERMIT <br /> <br /> <br />.3 <br />i 41 ^i'" 1 w i : r'1 Vr{ REQUIREMENT <br />i <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE <br /> prepared under my direction or supervision in accordance with a system designed <br />® <br />ennis ones to assure that qualified personnel properly gather and evaluate the information <br />Hydrologist I submitted. Based on my inquiry of the person or persons who manage the system, <br />the information <br />athering the information <br />onsible for <br />tl <br />e <br />di <br /> , <br />g <br />rec <br />y r <br />sp <br />or those persons <br />l <br />t <br />li <br />f <br />d <br />d b f <br />G 1 <br />(970) 27r,-59.09 comp <br />e <br />e. <br />, true, accurate, an <br />e <br />e <br />submitted is, to the best of my knowledge an SIGN URE OF PRINCIPAL EXECUTIVE 4? 6 <br /> I am aware that there are significant penalties for submitting false information, OF CER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATION5 (Rererence an arracnmenis nere) A,4 # <br />fill, "i ??•t 0 D)'UE <br />?I .O Tml!,'•. ",?, ?.. ? 4• <br />..,y. .I 5. r,i3i ,..?3 *.. r'".-i i__! ? , !. I `'_l `r) :?:. ?3..-.? ?i -. 1 f <br />AislY <br />t`'21 •, .. .I.. <br />PAGE OF <br />EPA Form 3320-1 Rev. 3/99 Previous editions may be used. r: ; ; t :hS3tcE.4Tklflilri.