2014-11-20_REPORT - M2011026

• Permit No: M2011026
• IBM Index Class Name: Report
• Doc Date: 11/20/2014
• Doc Name: Annual Fee/Report/Map
• From: Keyah Grande Lodge and Elk Ranch
• To: DRMS
• Permit Index Doc Type: Annual Fee/Report
• Email Name: GRM
• Media Type: D
• Archive: No

PERMITTEE NAME/ADDRESS (Include NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
Facility Name /Location if different) DISCHARGE MONITORING REPORT (DMR)
NAME hl ^4�eck�' �� {�' r 16�) !�� C (2 -16) (17-19)
ADDRESS COG-COG501529 -
^ PERMIT NUMBER I DISCHARGE NUMBER
FACILITY �a[�,i� (�yL,�I�1 , -, ,,�,� MONITORING PERIOD
LOCATION I-:'4ti� W }lu) lo�� PGn ^fin ��r�1rC �;� Ifl {' YEAR MO DAY YEAR MID DAY
ATTENTION FROM " I TO I a -IL r I '
(20 -21) (22 -23) (24 -25) (26 -27) (28 -29) (30 -31)
Form Approved.
Minor OMB No. 2040 -0004
Approval expires 10 -31 -94
F - Final
NO DISCHARGE 1�j
NOTE: Read instructions before completing this for
COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
EPA FORM 3320 -1 (REV. 948) Previous editions maybe used.
(REPLACES EPA FORM T -40 WHICH MAY NOT BE USED)
000 U 3i 9 00'.'18• I u 33
PAGE
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NAMErrITLE PRINCIPAL EXECUTIVE OFFICER
I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND
AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON MY
TELEPHONE
DATE
INOUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING
THE INFORMATfON, I BELIEVE THE SUBMITTED INFORMATION IS TRUE, ACCU-
RATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES
�
L •�
j/J�rl
FOR SUBMITTING LE INFORMATION, E OF FINE
M § 001 ANO 333 U.S C. 131POSSIBILITY
AND IMPRISONMENT. SEE 18URS CT
(Penalties under these statutes may include fines up to 810,000 and or maximum
] J( V
TYPED OR PRINTED
SIGNATURE OF PRINCIPAL EXECUTIVE
AREA
NUMBER
YEAR
MO
mprisonment of between 6 months and 5 years.)
OFFICER OR AUTHORIZED AGENT
CODE
COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here)
EPA FORM 3320 -1 (REV. 948) Previous editions maybe used.
(REPLACES EPA FORM T -40 WHICH MAY NOT BE USED)
000 U 3i 9 00'.'18• I u 33
PAGE