PERMITTEE NAME/ADDRESS (/nclude Faciliry Namr/Lacanon lDi$ermr) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form ApprOYed.
<br />NAME ,`.YF'~i ', ~:0 '~,'AI''PF+ VALLc`! C'.+r~_ '.:GRI'. DISCHARGE MONITORING REPORT (OMR) ,,,I~ r, OMB NO. 2040-0004
<br />ADDRESSeIItJtS 1, 2~<3 5UUTH. .< ECl4MAN PH CU442,' 154 •OCg A + 3~ IL%,S. .,~,,;
<br />°10'J EAST MINERAL CIRCLE PERMIT NUMBER DISCHARGE NUMBER F - `-i?d`~~_ ii!JUi(
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ICenity untler penalty of law shat t
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<br /> eubmiaed Is , to the best of my knowledge end beliel, tme, accurate, entl mmplere. SIGNATURE OF PRINCIPAL EXECUTIVE ~J "
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<br />TYPED OR PRINTED I em evrere that there are sjgnRCerlt penalties for submining false information,
<br />inclutlin the osslb~li ot7ihe nntl im risonment for Nnowi violations. OFFICER OR AUTHORIZED AGENT
<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence,all attachments here)
<br />r._ILRNAIE LIMITS FOR TSE 8< Si=TTLEADLE SOLIDS iLUC 'O A~F'LY (.RVLY I:- -_ ;.1-rF;. ;'~~-rift PF.ECIP EtiEPIi IS
<br />C~L.AIMED. SEP I. A. 2. PG iH, FUR BURDEN UF' PROUF REi3UIREMENi:7 OIL £. 6'P.EA.SE-~-~t.F' FCIOTNOTE F1, P~; 6
<br />EPA Form 3320.1 (REV 3/99) Previous editions may be used. OOG57 / 401 12~t~It~S~~rPART FORM PAGE 1 OF
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