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PERM177EE NAME/ADDRESS: .............. . SAMPLE NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) .... NAME: MOUNTAIN COAL COMPANY, LLC ......... DISCHARGE MONITORING REPORT (DMR) ...... ADDRESS: WEST ELK MINE C00038776 012 W CUTE WET TESTING AT 012A P.O. BOX 591 PERMIT NUMBER DISCHARGE NUMBER (SUBR MH) GUNIS MEASUREMENT SOMERSET CO 81434 EXTERNAL OUTFALL FACILITY: WEST ELK MINE MONITORING PERIOD MINOR LOCATION: APPX 1 MI E OF TOWN ON HWY 133 FROM To NO DISCHARGE SOMERSET, CO 81434 ATTN: KEITH R. WILLIAMS, PRESIDENT NOTE: Read instructions before c mpleting this form. PARAMETER QUALITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE ............... L�! VALUE ::::::::::::::::: VALUE I I UNITS VALUE I VALUE F VALUE I I UNIT EX OF ANALYSIS TYPE LC50 STATRE 48HR ACU SAMPLE (23) DAPHNIA MAGNA MEASUREMENT €sPl € € €€ IRA= , ... � : : :; :; : : : :; := :; :��: : : : : @ : :: : :::::::::[:::::::::: ttlF TAM3C 1 0 EFFLUENT GROSS SEE COMMENTS NO DISCHARGE PERCENT LC50 STATRE 96HR ACU SAMPLE (23) PIMEPHALES MEASUREMENT ....;:;:;:::::::: TAN6C 1 0 : :FI7's =f ..:...:.: .:.:.:-:.:. :- :. :. :. :.. :. :. :. :. :. :. :. :. :. :. :; : :, :;•.• -• ;::. EFFLUENT GROSSAJlf?Nki�IT _._..........__ _ — ...... PERCENT PERCENT,--.. .'`::::::: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :: SAMPLE [MEASUREMENT MEASUREMENT ...ATE : : :: '.:: '• : : : : : :' :;`;; : : : : : :` : : : : :; : :.. 31EQil � ..... ............................... SAMPLE MEASUREMENT COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) Forms by Wi1KowChem(707 )884- D645;p/n11090;v5.0;l/lf96 SEE 1.A.5, PP. 6-7, FOR DETAILS OF TEST PROCEDURE. REPORT LC50 — STATISTICAL POINT ESTIMATE WHICH IS LETHAL TO 50% OF THE TEST ORGANISMS, AND ATTACH ACUTE TOXICITY TEST REPORT FORM TO DMR. 00121/980409 -1716 PAGE 1 OF 1 .............. . SAMPLE . ................ .... ......... ...... ........... MEASUREMENT ELI. 17 ........... .......... ............... ::::::::::::::::: : : : : : : : :: : : : s: : : : : : : : : : : : : : : : : : : : : : : SAMPLE MEASUREMENT ....;:;:;:::::::: : : : :; : : :; : : :; : : :; : :: : :; : : :; :; :: ..:...:.: .:.:.:-:.:. :- :. :. :. :.. :. :. :. :. :. :. :. :. :. :. SAMPLE MEASUREMENT ...ATE : : :: '.:: '• : : : : : :' :;`;; : : : : : :` : : : : :; : :.. NAME / TITLE PRINCIPAL EXECUTIVE OFFICER TELEPHONE DATE 1 CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS WERE PREPARED UNDER MY ALIFIED PERSONNEL DIRECTION OR SUPERVISION IN ACCORDANCE WITH A SYSTEM DESIGNED TO ASSURE THAT OU NE PROPERLY GATHER AND EVALUATE THE INFORMATION SUBMITTED. BASED ON MY INQUIRY OF THE PERSON OR ' 'PERSONS WHO MANAGE THE SYSTEM, OR THOSE PERSONS DIRECTLY RESPONSIBLE FOR GATHERING THE INFORMATION, THE INFORMATION SUBMITTED I5• TO THE BEST OF MY KNOWLEDGE AND SEUEF, TRUE. ACCURATE. Weston Norris AND COMPLETE 1 AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION. SIGNATURE OF PRINCIPAL EXECUTIVE 970 - 929 -5015 10/13/2014 INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR KNOWING VIOLATIONS. TYPED OR PRINTED OFFICER OR AUTHORIZED AGENT MM/DDNYYY COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) Forms by Wi1KowChem(707 )884- D645;p/n11090;v5.0;l/lf96 SEE 1.A.5, PP. 6-7, FOR DETAILS OF TEST PROCEDURE. REPORT LC50 — STATISTICAL POINT ESTIMATE WHICH IS LETHAL TO 50% OF THE TEST ORGANISMS, AND ATTACH ACUTE TOXICITY TEST REPORT FORM TO DMR. 00121/980409 -1716 PAGE 1 OF 1