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PERM ITTEE NAME. /ADDRESS (Include Facility Name /Location if Different) <br />NAME: Moffat County Mining LLC <br />ADDRESS: 29515 Routt CR 27 <br />Oak Creek, CO 80467 -9704 <br />FACILITY: WILLIAMS FORK MINE <br />LOCATION: 1030 C 107 <br />CRAIG, CO 81626 <br />A "l-TN Jerry Nettleton, Supv <br />v6oCHARGE NIONiRURiWo FtEs -, iRu libillik, <br />000034142 024 -A <br />PERMIT NUMBER I DISCHARGE NUMBER <br />MONITORING PERIOD <br />MM /DD/YYYY MM /DD/YYYY <br />01/01/2014 1 1 03/31/2014 <br />"!"'E ,c <br />DMR Mailing ZIP CODE: 80467 -9704 <br />MINOR <br />Mine Dewatering to Sedimentation Basin Prior to Discha <br />External Outfall <br />No Discharge <br />NAME /TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify under penalty of iawthat mis document and all aaachments %ere prepared under my direction or <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />FREQUENCY <br />SAMPLE <br />PARAMETER <br />EX <br />OF ANALYSIS <br />TYPE <br />VALUE <br />VALUE <br />UNITS <br />VALUE <br />VALUE <br />VALUE <br />UNITS <br />Oil and grease visual <br />SAMPLE <br />- -- <br />AUTHORIZED AGENT <br />AREA Code <br />* * * * ** <br />ee— <br />MEASUREMENT <br />840661 0 <br />PERMIT <br />* * * * ** <br />Req. Mon. <br />Y =1,N =0 <br />* * * * ** <br />' * * * ** <br />* * * "* <br />* * * * ** <br />Twice Per <br />VISUAL <br />Effluent Gross <br />REQUIREMENT <br />INST MAX <br />Month <br />NAME /TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify under penalty of iawthat mis document and all aaachments %ere prepared under my direction or <br />TELEPHONE DATE <br />supervision in accordance with a system designed to assure t`tat qualified personnel properly gather and <br />valuate the information submitted Based on my inquiry of the person or persons %fio manage the <br />system or those persons directly responsible for gathering the information the information submitted is <br />• <br />GiA l• C 6°` `5/ �' <br />to the best of my knowledge and belief true accuraee and complete I am aware that there are <br />possibility of fine and im <br />significant penalties for submitting false information including the imprisonment for <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />nowng violations <br />AUTHORIZED AGENT <br />AREA Code <br />NUMBER M /DD <br />I TYPED OR PRINTED <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Oil and grease sample required if visible sheen is observed. Otrly sampling instructions - I C 12, pg 11. <br />=i' <br />Form ; <2n- i uCv;l Previous editions may be used. <br />