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PERMITTEE 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 CR 107 <br />CRAIG, CO 81626 <br />ATTN: Jerry Nettleton, Supv <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />000034142 024 -A <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />MM /DD/YYYY MM /DD/YYYY <br />07/01/2015 09/30/2015 <br />Form Approved <br />OMB No. 2040 -0004 <br />DMR Mailing ZIP CODE: 80467 -9704 <br />MINOR <br />Mine Dewatering to Sedimentation Basin Prior to Discha <br />External Outfall <br />No Discharge LL GJ <br />PARAMETER <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <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 />/ <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />* * * * ** <br />* * * * ** <br />* * * * ** <br />* * * * ** <br />TYPED OR PRINTED <br />nkra cone <br />PERMIT <br />REQUIREMENT <br />* * * * ** <br />Req. Mon. <br />INST MAX <br />Y =1;N =0 <br />* * * * *' <br />* * * * ** <br />* * * * ** <br />* * * * ** <br />EPA Form 3320 -1 (Rev.01106) Previous editions may be used. <br />Twice Per <br />Month <br />VISUAL <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <br />/ <br />TELEPHONE <br />DATE <br />supervision accordance with a system designed to sure that qualified personnel properly gather and <br />valuate the the nformation submitted Based on my inquiry of the person or persons who manage the <br />system, r those persons directly responsible for gathering the information the information submitted is. <br />to the best of my knowledge and belief, true accurate and complete. I am aware that there are <br />sgnifca t penalties for submitting false information. including the possibility of the and imprisonment for <br />'�! ✓/ <br />/ <br />d y l / ,�J/,% %et -7 <br />JJ I �u ^ V �1 I ` �S ° �' <br />1 <br />��� J ?�' -��' <br />/ <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />vowing violations. <br />AUTHORIZED AGENT <br />TYPED OR PRINTED <br />nkra cone <br />I NUMBER <br />MM /DD /YYYY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Oil and grease sample required if visible sheen is observed. Qtrly sampling instructions - I.C.12, pg 11. <br />EPA Form 3320 -1 (Rev.01106) Previous editions may be used. <br />07/10/2013 <br />Page 4 <br />