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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if <br />993W., GCC Energy LLC <br />ADDRESS: 5652 County Road 120 <br />Hesperus, CO 81326 <br />FACILITY: KING COAL MINE <br />LOCATION: 4424 COUNTY ROAD 120 <br />HESPERUS,CO 81326 <br />ATTN: DAN REDETZKI, MINE ENGINEER <br />NATIONAL POLLUTANT DISCHARGE ELEVENATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />COG850001003-A <br />I certify order penalty of law that this doeumenr and nu artxarments were preparedm, der my <br />1heo t or supervisiocordance with a sem ystdesigned to assure that qualified <br />rNn m ac <br />PERMITNUMBER <br />DISCFLSRGE NUMBER <br />MONITORING PERIOD <br />MM/D <br />SAMPLE <br />TYPE <br />I MM/DD/YYYY <br />10/01/2016 <br />UNITS <br />1 12/31/2016 <br />Form Approved <br />OMB No. 2040- 0004 <br />DMR Mailing ZIP CODE: 81326 <br />MINOR <br />(SUBR GB) LPLTA <br />SURFACE RUNNOFF TO HAY GULCH <br />External Outfall <br />No Discharge® <br />PARAMETER <br />I certify order penalty of law that this doeumenr and nu artxarments were preparedm, der my <br />1heo t or supervisiocordance with a sem ystdesigned to assure that qualified <br />rNn m ac <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 />Off and grease visual <br />SAMPLE <br />MEASUREMENT <br />YYY <br />/DD/Y',. <br />8406610 <br />Effluent Gross <br />PERMIT' <br />REQUIREMENT <br />****** <br />Req. Mon. <br />INST MAX <br />Y=1;N= 0 <br />****** <br />*****" <br />****** <br />****** <br />Twice per <br />Month <br />VISUAL <br />NO DISCHARGE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify order penalty of law that this doeumenr and nu artxarments were preparedm, der my <br />1heo t or supervisiocordance with a sem ystdesigned to assure that qualified <br />rNn m ac <br />TELEPHONE <br />DATE '.,. <br />mel properly gather and evaluate the Wornatlon subrNtted. Based oa my inquiry of the <br />970-3855-45528 <br />01/02/2017 <br />V.P.rson <br />G1naNanee, `% <br />or persons who menage the system, or those persons directly responsible£r gathering <br />heWormanon,theinformationsubmittedis,tothebestofmylrtrledgesadbelief,rme, <br />accurate, and complete. I am aware that there are sigmrcmt penahles for submitting false <br />includng the possiblliryoffins sad imprisonment for lot oris, violations. <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />AUTHORIZED AGENT <br />TYPED OR PRINTEDormation, <br />a NU <br />AREl codMB]R <br />YYY <br />/DD/Y',. <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />SETTLEABLE SOLIDS LIMIT WAIVID FOR10- YR, 24 HR PRECIP EVENT SUBJECT TO 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.01/06) Previous editions may be used 12/03/2015 Page 1 <br />