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' <br />PERMITTEE NAME/ADDRESS pM,Ar PacelryN~v/faplm l/Dlpmnp <br /> <br />IEir~ ss CA.-.1 _1R )7ti~TC)N MINE <br /> <br />-~~ DJ3a:::;7 <br /> ~„~ <br /> <br />I <br />~ CV <br />H <br />~ <br />I <br />I <br />l <br />NATIONAL POLLUTANT DISCHMOE EDMINATON SrSTEM (NPDESI <br />DISCHARGE MONITORING REPORT lOMRI <br />l1-161 17-I31 <br />- m F -.I <br />PERMIT NUMBER DISCHYJIGE NUMBER <br />1 13) i MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM ,) L Ou ) L TD v i J ~ ~ O <br />/IQ7r/ 01-1.T/ U4J5/ /ACJ7/ URJe/ IM.ifl <br />Form Approved. <br />F. D I J A G T p ONI~~ No. 2040-0004 <br />(5' :I ~ r V) T AP ~ovell ~Prl 0~-3t-96 <br />II <br />F - FIaAL <br />F:P:): <br />NOTE: Reed Inetruclione be}ori CbMOletln9 this form. <br />~ <br />PARAMETER U !3 Grd Onry1 QUANTITY OR LOADING !1 Grd Onl 1 QUANTITY OR CONCENTRATION <br />Y NQ FREQUENCY SAMPLE <br />I1J <br />/3137 o 14653 !5461/ /38-15 /4653) !54611 QF <br />1 EX <br />NUrsls TYPE <br />~ _ AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS !eI-6.f! A <br />/54-581 &701 <br />~[L .9VU ::t ;.9-iu SAMP'_ ..-.. ~. { 94) <br />~ ` ~ ' r+ - <br />' MEASUREFl~NT ' ' ' ` ' <br />r : ~ : 3 L <br />r <br />4.)D~ 1 J PERMIT <br />:0' ~. ` <br />yP D:3T <br />°~`:=1 <br />k;-:c ;::y .~ <br />.,.« <br />.': c:' >r t' <br />.C <br />'c <br />FI <br />Y <br />i I[Y)r,l <br /> REDUIREMENT , <br />, <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT r <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT v <br /> REQUIREMENT (~ <br />I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMERITLE PRINCIPAL EXECUTNE OFFICER 1 CERTFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINEO AND <br />AM FAMILIAR NATH THE INFORMATION sUBMITTED HEREIN: AND BASED ON I I TELEPHONE DATE <br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIA7ELr RESPONSIBLE FOR /~^- ~ <br /> <br />/ <br />OBTAINING THE INFORMATION, 1 BFIIEVE THE sVBMITTEO INFORMATION IS <br />TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE ~ <br />(I <br />•~~ <br />~ <br /> <br /> <br />SIGNIFCANT PENALTIES FOR 6UBMITTINO FALSE INFORMATION, INCLUDING ~' + <br />y L, / <br />• 1 <br /> <br />J/fl ~ <br />71 <br />1 <br />t ~ <br />THE POSSIBIUTr OF RNE AND IMPItI30NMENT. SEE 18 U.S.C. 1 1001 AND ]] I <br />61CINATURE OF fRiINCI <br />E <br />E ~ <br />~/1/ /L r <br />- <br />TYPED OR PRINT U.S.C. f tJte. lPMWeia +m0a. Nar memo v+aY AtcAda faAra +e ro f 10,000 <br />An[nnrairxan MwlsmlrH Ol MnrwnemenUa rg6Yra! PAL <br />I <br />X <br />CUTNE <br />OFFICER OR AUTHORIZED AGENT ARE4 <br />NUMBER <br />YEAR <br />/MO/ <br />t~( <br /> CODE y <br />..vmmu.,a nnv cnr u-,nn nvn err nn. v.v~r..,vn., msrsancv en ~.mciunen.a nerq <br />., .::I'LEA3LE 3DLCD)1LI'1[? A6i'LIc:.; ~)hLy I!' := 1.:-Y~a 20-HR ~?L..Lt ..Vf.Ai i5 =LA1vFC. TP "S,AI" AI'P{)YF`; ",'+ <br />A ,~:;Ua Iii F, INJ!I LCNIfS 'BILL iJf is p,?e Ll`_.~J TJ REPO?T'1 '1 ~: rljv Gr.'1~i.. ~--5 °, I. o. 1.5a PG ~tiD Z. ~a LBa ,., ga <br />EPA grin Zd-"1`Y08= 1 revidue edition ey be" IREPLACE6 EPA FORM T-00 WHICH MAY NOT BE USED.1 PAGE OF <br />