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PERMITTEE NAME/ADDRESS 1Include Facilig A'amelL,carion if lhf/erenfl <br />NAME <br />ADDRESS <br />ROX 671; <br />DFN _ 639 <br />FACILITY r4 MINE C: i' ' P L F Y <br />LOCATION ti I: rJ co 81639 <br />Y KARD, RE ;LANAT ION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 1040-0004• <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> EX OF TYPE <br /> AN <br />ALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT - 1 <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />I <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 />NAMEfTITLE PRINCIPAL EXECUTIVE OFFICER I certify under la•mdt% of luw that this document and all attachments were <br />d <br />d <br />di <br />ti <br />i <br />i <br />i <br />d <br />ith <br />t <br />d <br />i <br />d / TELEPHONE DATE <br /> prepare <br />un <br />ance w <br />er ntt <br />rec <br />on or supers <br />s <br />on <br />n accor <br />em <br />es <br />gne <br />a sys <br /> to assure that yuaiiried Personnel properly gather and etuluate the information <br /> submitted. Based on ms imluin or the person or persons who manage the ssdem, <br /> or those persons directly respnsible for gathering the information, the information R <br /> submitted Is, to the bed or my knowledge and belief, true. accurate, and complete. <br />1 am aware that th <br />r <br />nificant <br />s for s <br />bmittin <br />lse information <br />rc si <br />n <br />lti <br />f SIGNAT E OF PRINCIPAL EXECUTIVE i <br /> <br />TYPED OR PRINTED g <br />e <br />e a <br />g <br />pe <br />e <br />u <br />a <br />. <br />a <br />including the p,%ibilit% of fine and imprisonment for knowing .rotations. OFF ER OR AUTHORIZED AGENT <br /> <br />, AREA <br />D NUMBER <br />CO <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 is a 4-pact form.