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PEAMITTEE NAME/ADDRESS(7.A.&FoeWryN..WL atie #/D(04nwr) <br />NAME <br />ADDRESS " <br />1 O. BOX 187 <br />IG CO 81626 <br />FACILITY ''PER MINE <br />LOCATION I G CO 81625 <br />NATIONAL POLLUTANT 04SCHMOE ELIMINATION SYSTEM //NPOES) <br />DISCHARGE MONITORING REPORT (DA4R) <br />PERMIT NUMBER hSCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB No 2040-0004 <br />MINOR <br />(SUHR JC) <br />F - FINAL <br />POND #5 TO NO NAME GULCH <br />MOFAT <br />NOTE: Reed In+tructlone Woes completing this form. <br /> NO pREOUENCr SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION . <br />EX OF <br />ANALYSIS <br />TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />i SAMPLE <br /> MEASUREMENT <br />AL ? <br />- i. ;=j <br />1 0 0 PERMIT ?t## # REPORT tt???3i? #it?r??t# ??#??? ?;: . • <br />, <br />.1 NT GROSS VF-. REQUIREMENT INST MAX u!!•ITt <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br />EQUIREMENT <br /> R <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />I remits under pens t7 ¦. that Ihb document ¦nd oil attachmemts wen TELEPHONE <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER prepared antler my direction or supervision In accordance with ra system dWgned DATE <br />- to sere that auaMfled personnel V. We 12 ether and evaluate the Inrnrrrratlon . <br />?- submitted. Based on my Inquiry of the person or peraont; who marrage the gstem, <br />/? - - a those person directly responsible for ptherlrq the Informai the larorrmtlem <br />submitted Is, so the best of my knaretedge and belief. true. accurate, and compkte. <br />- ' "? ---- I am aware dal There are sttnllfcunt peraftle for Submitting false information. SIGNATURE OF PRINCIPAL EXECUTIVE <br />RIZED AGENT <br />T AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br />TYPED OR PRINTED Including the poaslbnlq or line and Imprisonment for knowing vW&tlwm HO <br />OFFICER OR AU CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ION •tfachments here) <br />1 f; ,-BLF.. SOLIDS LIMIT APPLIED FOR C=10YR, 24HR PRECIP EV[~, <br />iw? <br />I EPA Form 3320-1 Rev 31W Previous editions may be used