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PERMITTEE NAME/ADDRESS (Include Facility Nama4 ocation if Different) <br />NAME: Hayden Gulch Terminal Inc <br />ADDRESS: PO Box 670 <br />Hayden, CO 81639 -0670 <br />FACILITY: HAYDEN GULCH LOADOUT <br />LOCATION: 2 MI S OF TOWN, OFF RCR 53 <br />HAYDEN, CO 81639 <br />ATTN: Roy Karo, GM <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />COG850008 001 -A <br />PERMIT NUMBER I FIDISCHARGE NUMBER <br />MONITORING PERIOD <br />MM /DD/YYYY MM /DD/YYYY <br />07101/2014 09/30/2014 <br />Form Approved <br />OMB No. 2040 -0004 <br />DMR Mailing 27P CODE: 86001 <br />MINOR <br />ROUTT <br />POND (SW /4) TO DRY CRK/YAMPA <br />External Outfall <br />No Discharge <br />PARAMETER <br />I certify under penalty ol lawgmtthilcl— cnt and all anachmentawere prepared under mydir .donor <br />aupery ith islon In accordance w a system designed to assure that qualified personnel properly gather and <br />valuate the Information submitted. eased on my inquiry of the person or persons who manage me <br />system, or those persons directty respon¢ble for gathering the information, the information submitted is, <br />to the best of my knowledge and belief, true, accurole, and complete. I am aware that there are <br />si gnificantpenoltleafor submitting falseInforma lion, including the possibility of One and imprisonment far <br />owing valations. <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />EX <br />FREQUENCY <br />OF ANALYSIS <br />SAMPLE <br />TYPE <br />VALUE <br />VALUE <br />UNITS <br />VALUE <br />VALUE <br />VALUE <br />UNITS <br />Oil and grease visual <br />840661 0 <br />Effluent Gross <br />SAMPLE <br />MEASUREMENT <br />•'' "' <br />EPA Form 3320 -1 (Rev.0110G) Previous editions may be used. <br />.' "" <br />Page 2 <br />PERMIT <br />REQUIREMENT <br />• "• "' <br />Req. Mon. <br />INST MAX <br />Y =1;N =0 <br />" "" <br />I <br />' "' "" <br />" "' "" <br />'` "` "` <br />I <br />Twice Per <br />I Month <br />VISUAL <br />NAME /TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify under penalty ol lawgmtthilcl— cnt and all anachmentawere prepared under mydir .donor <br />aupery ith islon In accordance w a system designed to assure that qualified personnel properly gather and <br />valuate the Information submitted. eased on my inquiry of the person or persons who manage me <br />system, or those persons directty respon¢ble for gathering the information, the information submitted is, <br />to the best of my knowledge and belief, true, accurole, and complete. I am aware that there are <br />si gnificantpenoltleafor submitting falseInforma lion, including the possibility of One and imprisonment far <br />owing valations. <br />' <br />TELEPHONE <br />(�'� l'' <br />�(3 � y <br />Af2FA COdQ NUMBER <br />DATE <br />®/ lLi <br />! ` <br />MMIDDrtYYY <br />�, �� ��� <br />o�Vl C✓s'vrti� <br />t!l ,� �� <br />C <br />SIGN RE OF PRINCIPAL EXECUTIVE OFFICER OR <br />AUTHORIZED AGENT <br />TYPED OR PRINTED <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />SETTLEABLE SOLIDS LIMITS WAIVED FOR 10 -YR, 24 HR PRECIP EVENT SUBJECTTO BURDEN OF PROOF REQUIREMENTS INPART I.B.6. ANY ADDITIONAL DATA SHALL BE SUPPLIED TO THE <br />DIVISION WITHIN 48 HOURS. <br />EPA Form 3320 -1 (Rev.0110G) Previous editions may be used. <br />03/28/2014 <br />Page 2 <br />