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PERMITTEE NAME/ADDRESS ilnclade Facililr.vame/Location if ix fermi) NATI0f1AL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY _•:a ;1If+E ?'O( t'! Eh MONITORING PERIOD <br />LOCATION YEAR MO DAY Y FAR M DAY <br />DEN C O E4 1 ~. FROM TO <br />Y Ki' REI, RECLAMATION MANAGI: <br />Form Approved. <br />OMB No. a040.0004 • <br />MINOR <br />(SUDR JC) <br />F - FINAL <br />nISCHARGE TO SAGE CR <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT -? <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE f ` <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certil> under prndts of law that thls document and all attachment, were <br />o <br />• di <br />li <br />isio <br />i <br />with <br />s <br />t <br />d <br />i <br />d <br />d <br />d <br />d TELEPHONE DATE <br /> prepare <br />un <br />er m <br />rec <br />nn or %uprn <br />n <br />n acc <br />ance <br />a <br />ys <br />em <br />e <br />gne <br />r <br /> to assarr that qualifird per,omid prupert? gathrr and evaluate the information <br />submitted. Hxved nn my ioquin of the person or persona who manage the system. <br />or thusc penons dlraal> responablr for gathering the information. the Information <br />\ <br />\ <br />, <br />- -- t <br /> submitted ts, to the best of m% knowledge and belief, true, accurate, and complete. <br />I <br />h <br />h <br />i <br />d <br />f <br />b <br />i <br />i <br />f <br />k <br />i <br />f <br />i $IGNAT E OF PRINCIPAL EXECUTIVE <br />N <br />A , J <br /> <br />TYPED OR PRINTED am aware t <br />at t <br />ere arm % <br />gnificant pem <br />tia._ <br />or su <br />ng <br />a <br />e <br />ormat <br />on, <br />m <br />tt <br />n <br />including the pmsibility of fine and imprisonment for knowing violation. OFFI <br />R OR AUTHORIZED AGENT AREA <br />CO NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This iti a 4-part form. PAGE OF