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PERMITTEE NAME/ADDRESS (include Facility ;dame/Location if iNfferent) <br />NAME <br />ADDRESS <br />BOY <br />"!EN CO 81639 <br />FACILITY <br />LOCATION EW co 61639 <br />Y :KAROr RECLAMATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPOES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 3040-00040 <br />MINC r-< <br />(SUBR <br />F - FINAL ROU <br />DI5CHARGE TO SAGE CREEK <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 :. j /. <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT _ <br /> <br />PERMIT -7 x- Us <br />- <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ,.^ r;., <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ! <br /> PERMIT , . ?., _... .. r <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT / <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ` <br /> PERMIT _ i+ - - - <br /> REQUIREMENT i ' <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif% under Penalit of law that this document and all attachments were <br />tio <br />o <br />o <br />a <br />d <br />de <br />s di <br />e <br />s <br />r <br />s lo <br />i <br />a <br />da <br />e with a -le <br />t d <br />si <br />d - <br />•? TELEPHONE DATE <br /> pnyr <br />r< <br />un <br />r m <br />r <br />c <br />n <br />r <br />up <br />r <br />on <br />n <br />cc <br />r <br />nc <br />c <br />gae <br />n / <br /> to a?wre that qualified Personnel proprri% gather and e%aluate the information ^?? { <br /> •uhmitled. Raved on m* inquire of the person or per-ms who manage the s%strm. <br /> or Ilwnr pem%directh resrym%ible for gnthering the information. the informatMn <br /> %uhndtted 6• to the het of nn knowledge and belief, true. a curair. and cumpktr. <br />12M awar <br />th <br />t there ar <br />si <br />nifi <br />t <br />s fo <br />ati <br />n <br />lti <br />b <br />itti <br />ls <br />infor <br />n <br />f <br />SIGNAT RE OF PRINCIPAL EXECUTIVE L . <br />? <br />TYPED OR PRINTED pe <br />. <br />e <br />a <br />c <br />can <br />a <br />e <br />r w <br />m <br />ng <br />a <br />e <br />m <br />o <br />g <br />including the 1-ihilit. -d rnr and imprisonment rise knowing siolatioj- OFF ER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />ter, c;, T P (-: +F?IT-, ; mac. <br />EPA FNm 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part form. PAGE 'OF