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PERMITTEE NAME/AODRESS(y..clead.)r-&,,N..?L?arrant/DC&..r) <br />NAME - <br />AOORESS. <br />BOX 483 <br />:DNIA CO 81428 <br />FACILITY - - '-.'-J I E NO. ? M I NE <br />LO"'AT" !NIA CO 81428 <br />i LL I AM A. BEAR JR., MINE MIvR <br />NATIONAL POLLUTANT DISCHMOE ELIMINATION SYSTEM NPOE31 <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHAME 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 MHt) <br />F - FINAL DELTA <br />5R; DEER TRL DTC OR UNMD TRIB <br />NOTE: Reed klatrvctions before complet" this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FRYOVENCY SAMPLE <br /> <br />E OF <br />E <br /> X ANALYSIS TYP <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE r ;: s <br /> MEASUREMENT j <br />:4v?• PERMIT EE ISSUE' <br />- FL . ! REQUIREMENT I I4ST IV, <br />y <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <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 /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAMEnME PRINCIPAL EXECUTIVE OFFICER I eerilly " e, pen. 1y o fl.. that this document and all a11achment, were TELEPHONE <br />I I DATE <br />pmps"d under my direction or sup. <br />, m In accordame with a Men. designed <br />to asar.n th 11 qualified penonael property gather and evaluate the Infonnalbn <br />srbmltled. ea rd on my Inquiry of the person or persons who manage floe system, <br />or those persom directly respo rsible for gathering the Intormstle t. the Infornaallon "-- <br />submitted Is. to the best or my knowledge and bellef, true. a rate. and complete. <br />I am ..am that mere are s11nin-1 penalties For submittin <br />SIGNATURE Of PRINCIPAL EXECUTIVE <br />false Info don <br />F <br /> g <br />, <br />ARE <br />TYPED OR PRINTED Ir.IWIng the possibility of floe and imprisonment for knowing Anlatkm& <br />OFFICER OR AUTHORIZED AGENT <br />DE NUMElEI+ <br />CO <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANA I IvN Ur AM T vlvi-n I Ivrva frrererence on errecnmenrs nsrsf T? <br />NP PRFC T° F`..1FrN!T T q "t A T MED r r "'AIM A'RPROVFn ?3'f t,IQCL?, <br />in. <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This IS 1 4-Part form. PAGE OF