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PERMITTEE NAME/ADDRESS l11r1rdr F.eWry NaWLeemla~ IJDI~r^9 <br />NnME _POLDEEHQBM COAL COMPANY <br />ADDRESS@OADSIDE MINE, M ,~, 5 PORTALS <br />P.O. 13uX 1430 <br />PALISADE CO 8156 <br />FACILITY <br />LOCATION <br />AS'Ttr: JOTIN A. t':'VAH, N4t~IDENT <br />T: <br />.-)IATIONK.V.pdLLUiu+iDlsgNU+G~feMlN~noNSZSrEM-7NPDES/ _. _ :-.__.-_._ __c : -EGUD~APProved. ' <br />-_ _--_ .T~$. 7~ .A9 RFIIRIN, -~3f REPORT /OM~R9~~ ~ - o ~(~0-0004 <br />~«~ ($DgR YC) Pero a e71plte>~05-31-$ <br />PERMIT~NUMBER DISCHARGE NurAeER F- P I f A L J Lt <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAV <br />FROM U U TO <br />(16711 l72-231 !7(.751 !16171 l7B-191 !30-311 <br />~INCR <br />~~~ NO DISCiiARGE ~ #'`~ <br />NOTE: Read Irotructlane baton eompletinp this lorm. <br />AARAMSTER - _ $~d~D~(y~ QUANTITY OR LOADING _ • Card Onl QUANTITY OR _CONCENTRATION FREQUENCY <br /> EX T <br />PE <br />137-371 ANALVSS Y <br /> AVERAGE .MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS (x7.6]1 (6I-IS81 /69701 <br />i ND GREASE SAMPLE ##04## ~ 9d) 45;9w# #0#;;# Ikd#;#+? <br />Y ISIi 1 L MEASUREMENT <br />~4U66 1 0 0 ~~.~~~RERMIT:~..... <br />... .:.. : ~#xIRP!a?N~..:: :;::~~~~~'.~'. QS=1 ~:~:+-Q.o# :-.~.1P.If1R+O?R#~ ~~;>7riQ~;:#~:. ;## ~~~ ~S~~tC ~ <br />~.r~~; <br /> <br />EFFLUENT 6R0$S YALU <br />REnuIREME.NT: , ... <br />.: <br />,.. ~. <br /> <br />: ~~........:tl ~: <br /> <br />MO=0 :.. ::r: ~:. :- :~ <br />' . <br /> SAMPLE - _ ~~ <br /> MEASUREMENT ~. ~ ~ ~ . <br />. <br /> ,... ... ... ,.e : ~ ~ <br />' <br />'~ F :E:.::,'. -z <br /> :REQUIREMENT. .~ ~.:::..::i,:c:. ~:~ .: :: •..: ~ :. ::; <br />....... <br />. <br />~; .. .:a:.; ~.. :~ <br />;.. <br />. <br />. <br />:r:'rS>-~ <br />~i:,ty `:< <br />,. <br />- <br /> <br /> SAMPLE .' .. ~ ~+ <br /> MEASUREMENT ~ ~ ~`' <br /> PERMIT :. ~. ~ <br />~ . ~: <br />.. ._ <br />... .:~~ .. <br />. ... <br />~ <br /> REQUIREMENT ' <br />;,~ .. . , <br />: <br /> <br />.. <br />~a ~ ~ SAMPLE - <br />%~'. MEASUREMENT <br /> PERMIT ~ ~ - ~ . <br /> .REQUIREMENT ~ ~ ~ .. <br /> SAMPLE . <br /> MEASUREMENT <br /> .~~.PERMIT :~ ~` <br />~ : <br />... .,. <br />. <br />- :REQUIREMENT ~ <br />. ~ ~: ~ .. <br />.. ,.. : <br />.:. : .. .. <br /> SAMPLE <br /> MEASUREMENT ~' <br /> PERMIT - ~ ~ ~ ' . .. <br /> ~NEQUIREMENT ~~ <br /> SAMPLE <br />' MEASUREMENT <br />~ <br /> PERMIT ~ ~. ~ .. ~ ~ - ~ .. ... <br />~ .. .. <br /> :REQUIREMENT ~ ~.~ ~. .... ~. :... ;. ~ . ~-. ~ . .. .. . <br />NAME/TRLE PRINCIPAL EXECUTIVE OFFICER I cERTIFV UNDER PF/1ALTY of uw rNAT I NAVE PERSONULr ExAMINED AND TELEPHONE DATE <br /> AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN; AND BASED OM <br /> <br />Shove r <br />TE MY INOUIRy OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br />OBTAINING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATON Is <br />, <br /> <br />'~ TRUE. ACCUMTE AND COMPLETE. I AM AWAAE THAT THERE ARE <br />SIGNIFICANT PENALTIES FOR SIIaMITTING FALSE INFORMATION, INCLWING ^ <br />y~] <br />~ ~~~ ~~~~ <br /> <br />~ <br /> <br />~ ( <br /> <br />D~ <br />!; O ~ THE POSSIBILITY OF NNE AND IMPW90NMENT. SEE 1a U.S.C. f 1001 AND 3] IONATURE OF NtINCIPAI E7tECUTNE / / I <br />1 U.S.C. E 1 ]10. (FMrlFir. u.dr err mvr. my NcArA. Fvr. +er ro S 10,OOD ~ A A <br />\ <br />TYPED OR PRINTED rpwmu:mwr MP'NarvmnrW Mewrn emoneu rdeYral OFFlCER OR AUTHORIZED AOENT CODE NUMBER YEAR MO DAY <br />}~ <br />i' <br />~~ <br />I <br />COMMENTS AND EXPLANATION OF ANV VIOLATIONS lRe/rrence sll ettschments here/ ' <br />SETTLEAffLE SOLIDS LIRITS APPLIES ONLY IF <=10SR,24HR PRP.CIPITATION EYFNT IS CLAIrED. PE@MITTEE HAS <br />;iURDEN OF P.RDO! WHEN AEQU(STiNG RELIEP FROM SETTLEIHLE SOLIDS PFIMAAY LIMITATIOlS. <br />EPA Form 3320.1 108-951 Previous editions may be used. (REPLACES EPA FORM TAO WHICH MAY NOT BE USED.1 U ~ 016 / 9 8 G 2 2 3-125 G PAGE ~OF <br />~. <br />