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PERMITTEE NAME/ADDRESS ifrrcluEr Forik Nmndl.ucation ii!)iifferm) <br />NAME <br />ADDRESS <br />13G:. <br />LA _ ' 4 <br />FACILITY H?f7 j 'r i F,l j' ; }•:_ <br />LOCATION ,LA <br />art <br />LANG WADE ? MINE MANAGER <br />NAT,CNAL POLLUTANT DISCHARGE EUMINATION SYSTEIJ 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. 2040-0004 <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE : -Y <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certifo under penalty of low that this document and all attachments weer <br />prepared under ms di x <br />rtion or supervision in ascordarae with a system designed <br /> <br />- . --_ TELEPHONE DATE <br /> <br />to assure that qualified personnel properh gather and evuluute the information _ _ <br />r- <br />t - <br /> submitted. Based on m? inquiry of the person or person who managr the system. <br />_ <br />? - or those persons direeth resprm%IW for galhrring the infurmation, the information <br />•' <br />- submitted is, to the hest or my knowledge aml bcbef. true. xruralc, and minplele. <br />_ _ 1 ant aware that there am %ignifkvnt penalties for submitting false information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED . <br />including the possibility of fore and imprisournenl for knowing vialatiuns. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />I,UmIVICN 1 J ANU tAYLANA I IUN Ur' ANT VIOLA I lvrva (rretere"Ge atl arfacnmenrs nere) <br />EPA Form 3320-1 (Rev. 3t99) Previous editions may be used. <br />[Eli FOR IOYRl24HR PRECIP EVENT <br />40 ` hiA,13 a 4-pak form.