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PERMITTEE NAME/ADDRESS (Include FaciU" NamelLoeafiun if D ifferent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM ? ((NPDES) <br />NAME DISCHARGE MONITORING REPORT (OMR) <br />ADDRESS <br />-I. Brix b PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY ` MONITORING PERIOD <br />'JECA !„, ,>" COMPLEX YEAR MO DAY Y R 0 DAY <br />LOCATION (DgN GO Sift FROM TO <br />.-jY KARO, RECLAMATION MANAGE` <br />Form Apprgved. <br />OMB No. 2040-0004 <br />MINOR <br />t SUBIR <br />F - Fir" <br />DISCHAF <br />NOTE: Read Instructions before comDletlnq this form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0. FREQUENCY SAMPLE <br /> OF <br />TYPE <br /> EX ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE t <br /> MEASUREMENT _ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT ' <br /> PERMIT <br /> <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/TtTLE PRINCIPAL EXECUTIVE OFFICER I certif, under pennlq orlaw that this documrnt and all attachment. were <br />d <br />d <br />di <br />TELEPHONE <br />DATE <br /> pepare <br />un <br />er mi <br />reoitm ur upervision in anxdawr with a syNrm deWmd <br /> It' aasurr that qualified penunnel priqu rh gather and eraiuate the informatio <br />h <br />i <br />d <br />R <br />d <br /> <br />su <br />m <br />tte <br />. <br />ai <br />on my inquiry (d the penon or prrsons who manage the system. n <br /> <br />or thnw• prr.tms dimity rnpnnsihlr for Rathering thr information, the information \ <br /> suhmil d is, to the best of my knowiedgr and bew true, accurate, and r <br />. <br />r. irm accurate. and c mple <br /> ti <br />I am aware that there art, si <br />nificant <br />rnaltin fo SIGNATUR OF PRINCIPAL EXECUTIVE <br />-- <br />TYPED OR PRINTED a <br />on. <br />g <br />p <br />r <br />int luding the possibifiq of fine and imprisonment for knowing siututions. OFFICE OR AUTHORIZED AGENT <br />1 AREA NUMBER <br />CODEJ YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br /> <br />EPA Form 3320-1 (Rev. 3W) Previous editions may be used. 00428 Thus a 4-part form.