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PERMITTEE NAME/ADDRESS (include Fmihfy.\'aatdl.ocalioa if lhffemntl NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY r t LJI'ir ` z MONITORING PERIOD <br />LOCATION EN CC) 8 1 FROM YEAR MO DAY TO YEAR MO DAY <br />r J+ ARO, RECLAMATION MANAGE <br />Form Approved. <br />MINOR OMB No. 2040-0004 . <br />t SURF J!-)F - FINAL. ROU <br />DSCHG TO TRIG/GRA5SY CREEK <br />NOTE: Read Instructions before cornniatino this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> OF <br />TYPE <br /> EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - I <br /> MEASUREMENT 1 I <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />i <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - <br />- ? <br /> MEASUREMENT ' • <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />r <br /> MEASUREMENT <br /> PERMIT u r . <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT p( (? <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 tertif} under penalt> of law that this document and all uttachment were <br />r <br />rtd u <br />d <br />di <br />th <br />i <br />i <br />i <br />d <br />h n TELEPHONE DATE <br /> pr <br />pa <br />lt <br />er m% <br />rec <br />m or suprrv <br />on <br />n accwr <br />s <br />ante wit <br />a %-tem designed <br /> to assure that yualifld per.onnel proprrly Mather and evaluate the inrormation <br /> wbmitled. Raid on my inyuin or the person or perwns who manage aw -ten, <br /> or those persons di-ti., rejxm%ible for gathering the infornution. the information <br />• t <br /> submitted is. to the bed of mt knowledge and belief. true, accurate. and complete. <br />I am aware that there are sirnirlc-ant prnahia for suhmitting fah( information SIGNA RE OF PRINCIPAL EXECUTIVE 1 " U <br /> <br />TYPED OR PRINTED . <br />including the Ix-ibdity or fine and imprisonmrm for knowing sMdatlom. <br />OF CER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DAY <br />V VIe11.IL1\ 1 J -- --11I'I1IV I? VI Itl? I <br />I-IUIallt,a all atlat,rll/1CIIlD I1411Cl <br />A REASONABLE I <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 00 10 :" 'T'his is a -I-OaWform.