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PERM17TEE NAMEIADDRESS llnclade FacMIY Aamelocotion if Mf/erent) <br />NAME <br />ADDRESS _ <br />BOX 670 <br />iAYPEN GO 81639 <br />FACILITY ; 1-:" A MINE COMPLEX <br />LOCATION DEN [[} 61639 <br />Y KARD, RECLAMATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No.,Ia04Q-W0& <br />MINOR <br />(SURF! <br />F - FINIAL R OL <br />DISCHARGE TO HUBBERSON GULCH, <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NQ, FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT V b ( ? -' "? <br /> PERMIT - <br /> REQUIREMENT r" <br /> SAMPLE <br /> MEASUREMENT --i ?' <br /> PERMIT - <br /> REQUIREMENT ?- r <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT k . <br />/ <br /> REQUIREMENT C-f- - :I, : -'r <br /> SAMPLE r I <br /> MEASUREMENT 1 ?' I J <br /> PERMIT ?t a <br /> REQUIREMENT - i.il , <br /> SAMPLE 0 <br />? <br /> MEASUREMENT ( <br />y' V <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE r• <br /> MEASUREMENT V <br /> I _ <br /> PERMIT T F. R <br /> REQUIREMENT ,'t1G <br /> SAMPLE r +t+ r+ <br />' <br /> MEASUREMENT i ( ? ! J V i > <br /> PERMIT ` <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certif. tinder I-Al, 41.1- that this document and all attachment eem TELEPHONE DATE <br /> Prepared under m? dirmlion or sup rnision in accordance eith a system designed <br /> to assure that qualified pennnnel properi} pathtr and e.aluale the infoern. ion I <br /> whmilted. Ra ed on my inquiry of the penon or perwms %ho manage the system. <br />or thaw persom dir-11. resp,rnsible for gathering the Information, the information <br />L-' <br />- <br /> submitted is, to the best of my knoaledgr and helief, true, anurate. and compieta <br /> <br />I ---m that then am si <br />nireeant <br />enalties for whmiuin <br />false information SIGNA, URE OF PRINCIPAL EXECUTIVE <br />I <br /> <br />TYPED OR PRINTED g <br />p <br />g <br />. <br />inrto ing the pxsihility of fine and imprWminent for kno%ing siolatiom. <br />OF ICER OR AUTHORIZED AGENT AREA <br />CODE NUMBER <br />YEAR <br />MO <br />DA <br />aevmlwen t A ANIJ r-ArLP161N 11V11 yr mtv r vtVL.M S Nitro frIVIVrCnt:e enr alsaennrrsnts nvrrl <br />fED FOR C=IOYR,24H <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. 0049"" T`IiW ii a 4-part form.