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PERMITTEE NAME/ADDRESS ilnrlude Facility.Name/fixation if rhfferent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS t.: F i.. <br />BOX PERMIT NUMBER DISCHARGE NUMBER <br />"CLA MONITORING PERIOD <br />FACILITY W HI]Ft I ZON M I <br />YEAR MO DAY YEAR MO DAY <br />LOCATION ;CLA FROM TO <br />Form Approved. <br />OMB No. 2040.0004 <br />MINOR <br />(SUBR MH) <br />C" _ C'T6tAI <br />3R&MINE DRNG TR IS TO TU D <br />•j" <br />NOTE: Read Instructions before completing this form. <br />INTRS <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 <br />( MEASUREMENT <br /> PERMIT <br /> <br />[R <br />'_;,=•?T <br />REP'-"= : <br />- - <br />L;F<, ,: <br /> EQUIREMENT DA I L _y ; + ! <br /> SAMPLE <br /> MEASUREMENT <br />- PERMIT ?EP'1F, <br />_ REQUIREMENT DAILY "IX <br /> <br /> SAMPLE <br /> MEASUREMENT <br />- PERMIT - ... iF,r It r <br />F F , REQUIREMENT :-,VG Ell <br /> <br /> SAMPLE <br />c, MEASUREMENT <br /> PERMIT R E f-' : <br /> REQUIREMENT -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 />NAME/T1TLE PRINCIPAL EXECUTIVE OFFICER I scrtih under prnalh of law that this document and all attachmmn were <br />d <br />i TELEPHONE DATE <br /> prepared under mi dimtion or suprm%iun in accorduner with v -lem <br />gned <br />e - <br /> to assure that gnalifed prrwnnel properi.s gather and evaluate the infurmation <br />-- --- submitted. llased on m? inquire of the perwn or perwm %be manatte the s%vlem, <br />or those person dirred, responsible fur gathering the information. the information ) <br /> accurate <br />and com <br />ittrd h <br />st of m <br />knowled <br />e and hellef <br />true <br />lete <br />h <br />to th <br />h ?,• <br /> <br />- y <br />g <br />, <br />. <br />. <br />p <br />. <br />w <br />m <br />, <br />e <br />e <br />f <br />i SIGNATURE OF PRINCIPAL EXECUTIVE '' ' <br />- <br />TYPED OR PRINTED ' I am aware that there arc significant pvmdtixs for suhmitting fake in <br />ormat <br />on, <br />including the ptwsibility or fine and impriwnment for knowing +iolntlorl. <br />OFFICER OR AUTHORIZED AGENT <br />A <br /> <br />REA NUMBER <br />CODE <br /> <br /> <br />EAR <br /> <br /> <br />O <br /> <br /> <br />AY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. %=? !-'= `-TTY1S3s a'p3tl tC>fi711•