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PERMITTEE NAME/ADDRESS Qnclode Fanlirv Name/Loranon t~Dt,((erenrJ NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form Approved.
<br />NAME S F.' Y £C A COAL C C C F A N Y DISCMARIGE MONITORING REPORT (DMR;9j n I Y U H OMB No. 2040-0004
<br />ADDRESSORAYER d ~,._.000CG(121 C1I l
<br />~ ~SUBH f1~ APProvalexpires•OS-31-98
<br />HAEDEN CO.dlb39 DISCHARGE NUMBER
<br />PERMIT NUMBER .~ - h'I1•JL- BOU77
<br />FACILITY ~ ~. .~ ~~ MONITORING PERIOD -° 9ED. P~CFC CSCGF 7C GS1SS) CSR.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAW THAT I HAVE PERS
<br />ATIO ONALLY E%AMINED AND
<br />D BASED TELEPHONE DATE
<br /> N SUBMITTED HER
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON EIN; AN
<br />ON MV
<br />SIBLE FOR OBTAINING
<br /> THE INFOAMATION. 1 BELIEVE THE SUBMITTED IN FORMATION IS TRUE
<br /> ACCURATE AND COMPLETE. I AM AWARE THAT TH
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<br />F ERE ARE SIGNIFICANT L~ C `
<br /> NALTIES FOR SUBMI
<br />ING
<br />ALSE INFORMATION, INCLUDING THE _
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<br />7
<br /> POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1B U.S.C. § 1 Wt AND 33~U.S;C. SIGNATURE OF PRINCIPAL EXECUTIVE V
<br />
<br />TYPED OR PRINTED § t3t9 (Penalties untler Mesa slelufas may include lines up ro Et0.000 entl;or
<br />mestmum tmpnsonment of betwaen6monlhs entl5years.) OFFICER OR q'UTHORIZED AGENT
<br />j AREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />M
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) a~s.~`' t
<br />TSS E IAOh LIhITS 4ill BE .tALVEO AND SE1'TLFAFLi: 9(LIDS~jl1IT AFFLLEC tCA C=lOYN,eUNF FFECIF EVEF7: 95S E
<br />IYOq LIHITS YAIYED FC,E J10YA,24HH PRECIP SYEMT SI)EdEC2 7C 6liADEA CF PFCCF IN I.A.:. C11 6 G6flPt-~EF
<br />1 i1-T_O. TOG MAYT\f [,YC_c CY TR 1 C
<br />EPA Form 3320.1 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-40'WHICH MAY.NOT.BE USED.) ~ ~ ', PAGE. OF
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