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PERMITTEE NAME/ADDRESS (lncludr Focilite.Nameworatiun iJDifferent) <br />NAME <br />ADDRESS !• r `- <br />C <br />FACILITY tt ;? ? f jJ,l T1 I i • E <br />LOCATION : L.QI C <br />:LANCE WADE, MINE MAN <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />F 14 =: FROM TO <br />ER <br />Form Approved. <br />OMB No. 2040.0004 <br />MINOR <br />(SU9R MH) <br />M -- INTERIM MN'TR? <br />5R&MINE DRND TO CALAMITY DRAW <br />NOTE: Read Instructions before completing 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 1,41. pit <br /> REQUIREMENT i•1 X - <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ; t;- it it <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 certih under penalty of law that this document and all attachments were <br />e <br />a <br />ed u <br />d <br />m <br />di <br />ctio <br />i <br />i <br />d <br />with <br />d <br />g <br />d <br />i <br />t <br />- <br />r- TELEPHONE DATE <br /> pr <br />p <br />r <br />er <br />% <br />re <br />n or uprn <br />s <br />on <br />n aec.w <br />ance <br />a sys <br />em <br />pa <br />n <br />rs - <br />--- <br /> <br />- to assure that qualified penomtel properly gather and e. duate the information - <br />- - -' - - ` _ submitted. Based on my imluiry of the perwn or persons w ho manage the system. , <br />t or those p mm, directly msponsible for gathering the information, the information - _; <br />- submitted is, to the best of my knowledge and belief. true. accurate. and complete. - <br /> I am aware that them am si <br />ninrant <br />enalties for uhmittin <br />rape inrormatiein SIGNATURE OF PRINCIPAL EXECUTIVE <br /> g <br />p <br />g <br />. <br />OFFICER OR AUTHORIZED AGENT AREA <br />TYPED OR PRIN D ittrluding thr prssibilits of fine and imprisonment for knowing sinlalions- <br />I NUMBER <br />CODE YEAR MO DAY <br />G(7MMLN 15 ANU LAF'LANA I IUN OF AN T vIULA I IUNJ (Kefefence all arracllments nefe) <br />rl0 1 T M T <br />EPA Form 3320-1 (Rev. 3199) Previous editiorts may be used. 0031