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PERMITTEE NAME/ADDRESS (Include FacilityName/Location 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 Scott Cowman, Sr Env Spec <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />COIG850008 <br />001-A <br />PERMIT NU:M:B:E:R::] <br />DISCHARGE NUMBER <br />MONITORING PERIOD <br />MM/DD/YYYY <br />SAMPLE <br />TYPE <br />MM/DD/YYYY <br />07/01/2015 <br />UNITS <br />09/30/2015 <br />Form Approved <br />OMB No 2040-0004 <br />DMR Mailing ZIP CODE: 81639 <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 of law that this document and all attachments were prepared under my direction or <br />supervision in accordance with a system designed to assure that qualified personnel properly gather and <br />valuate themformation submitted Based on my inquiry of the person or persons who manage the <br />system or those persons directly responsble for gathering the information, the information submittedistothe bestofmyknowledge and belieftrue, accurate, and complete I am aware that there are significantY <br />for submitting false information, including the possibility of fine and imprisonment for knowing <br />violations <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 />Oil and grease visual <br />840661 0 <br />Effluent Gross <br />SAMPLE MEASUREMENT <br />EUNITS <br />PERMIT <br />REQUIREMENT <br />****** <br />Req. Mon. <br />INST MAX <br />Y=1;N=0 <br />**'**" <br />****'* <br />*"*`" <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 />supervision in accordance with a system designed to assure that qualified personnel properly gather and <br />valuate themformation submitted Based on my inquiry of the person or persons who manage the <br />system or those persons directly responsble for gathering the information, the information submittedistothe bestofmyknowledge and belieftrue, accurate, and complete I am aware that there are significantY <br />for submitting false information, including the possibility of fine and imprisonment for knowing <br />violations <br />i-1---'UTIVE <br />TELEPHONE <br />DATE <br />�n15 ��, p 5 <br />�.. Q�[_ �j�`penalties <br />Y 6 G t ( } <br />l J <br />SIGNATURE OF OFFICER OR <br />AUTHORIZED AGENT <br />TYPED OR PRINTED <br />AREA code I NUMBER <br />MMIDDIYYYY <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.01106) Previous editions may be used. 04/20/2015 Page 1 <br />