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PERMITTEE NAME/ADDRESS (Include facility NamelLocation if Different) <br />NAME <br />ADDRESS <br />Bt7X <br />LA E <br />FACIUTY HOR 1.- <br />LOCATION LA <br />LANCE WADE, MINE MANAGI: <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 />OMS No. 2040-0004 <br />NOTE: Read Instructions before comoletinq this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT It ;: it k ..r v. <br /> REQUIREMENT M I N I mu ' <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t:• • x , : s _ _ .. ", 77 <br /> REQUIREMENT .. OR <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; F sr; r_rt?r, <br /> REQUIREMENT r"t ••' _' +; I i_ Y <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />is-• MEASUREMENT <br /> PERMIT - <br /> REQUIREMENT <br /> SAMPLE 7 7 <br /> MEASUREMENT <br /> PERMIT -. ,. _ <br /> REQUIREMENT • <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT r t r c: n . <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certif, under penally of [am that thin document and all attachments wen <br />d <br />d <br />di <br />» _ TELEPHONE DATE <br /> prepare <br />er my <br />recllon ur super <br />i.m in arcnrdanre with a ssstem designed <br />un .- <br /> br assure that qualified Personnel pruperii {;other and rsaiuate the information <br /> submitted. Nosed on mi % inquiry of the person or persons who manage the y+tem, `ry s ) i <br /> or those penons directly responsible for gathering the information, the information •??? <br />' submitted h, to the best or my knowledge and belief. true. accurate, and rnmpkte. f` ' <br /> I am aware that there arc significant penalties ror submitting false information SIGNATURE OF PRINCIPAL EXECUTIVE - - - <br /> . <br />i OFFICER OR AUTHORIZED AGENT <br />AREA <br />TYPED OR PRINTED including; the possihility orr <br />ne and imprisonment for knowing si:dations. I <br />NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br />-- a_e.r -1-w.• - e,... e.- . 1-- Inerer-- ou auaadnnenw rrcre/ <br />P EVENI <br />-F: <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used.