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PERMITTEE NAME/ADDRESS Inelude F'ardigv Nomr/lAwabon if lti ferenti <br />NAME _ <br />ADDRESS <br /> <br /> 3 <br />FACILITY 11: 1 <br />LOCATION I A C A <br />4C E WADE, MINE i <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 />MINOR OMB No. 2040.0004 <br />(SUBR MH) <br />M - INTERIM I V4. <br />5R&MINE DRNG TO CALAMITY URAW <br />NOTE: Read Instructions before completing this form. <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 „ I 'R ., r -. .r <br /> REQUIREMENT ?'f ' '; i 1' i :, if ;', X I •"0 ` <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT a u• ,r <br /> REQUIREMENT it-]'iR l-i: t"":'t: <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT x w _ . <br /> REQUIREMENT - D r= , ?'•i _ 1 ' <br /> SAMPLE <br />-"::-• MEASUREMENT <br />r. PER <br />MIT -z <br />- r7 <br />.t <br />i <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />- REQUIREMENT iIA T?-, f l <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT lk? <br /> REQUIREMENT r r'f c' T <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I Lerti4 under penal It, of law that this document and all attaehmrnis were <br />•d <br />di <br />i <br />W <br />I <br />d <br />i <br />h <br />t <br />d <br />i <br />d TELEPHONE DATE <br /> farepan <br />under ms <br />rect <br />on or %upen <br />on <br />n accor <br />ance w <br />t <br />a sys <br />em <br />es <br />gne <br /> b, assure thni qualirted personnel properil gather and esaiuate the information <br /> submitted. Rand am m} inyuin of the person or persons who marmite the setem, <br /> or those per % directly respomible for gathering the information. the information <br />i ii L <br />t - ' -' submitted is, to the bet of ms knowledge and belief. true, accurate, and amtpletr. SIGNATURE OF PRINCIPAL EXECUTIVE f t. <br /> <br />TYPED OR PRINTED I um aware that there are sigulfkant penalties for submitting false Information. <br />including the p?sihilitl or Fine and impri-aunrnt 6,t knowing sinlations <br />,. <br />OF <br />OR AUTHORIZED AGENT AREA <br /> <br />NUMBER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all attacnments here) <br />EPA Form 3320-1 (Rev 3,%) Previous editions may be used. TI1it k a 4-part form. PAGE OF