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EPA ID Number (copy hom tram I of Fonn 1) Continued from Page 2 AB,C, S D: See InstrueUOne before proceeding. Complete oho set of tables for each outfall. Annotate the outlall number in the space provided. cables VII-A, VII-B, end VII-C ere included on se orate sheets numbered VII-1 end VII-2. E: Potential discharges not covered by analysis - is any toxic pollutant listed in table 2F-2, 2F3 or 2F-4, a substance or a componant of a substance which you currently use or manufacture as an intermediate or final product or byproduct? Yes ist ell such llutants bebw No o ro Section N/A Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your tlischarges or on a receiving water In relation to your discharge within the last 3 years? Yes list e!1 sc~h llutanrs below No o ro Section N/A Were any of the analysis reported in item VII performed by a contract laboratory or consulting hrm? Yes (fist the name, address, and telephone number of, and pollutants ~ No (go ro Section )Q A Name B. Adtlress C. Area Code 8 Phone No. D. Pollutants Anal ed N/A 1 certify under penalty o! law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the Information submitted. Based on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information submitted is, to the best o/ my knowledge and belief, true, accurate, and complete. 1 am aware that there are significant penalties for submitting false information, including the possibility of /ine and imprisonment for knowing violations. A Name ti Ofliaal Title (type or poor) B. Area Code end Phone No. LANCE WADE, MINE MANAGER 303-864-2165 C. Signnture D. to Si nod Pape 3 013 EPA Form 3510-2F (Rev 1-92)