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PERMITTEE NAME/ADDRESS dnelude Faciliq.\anadLorarion iif mfferen(t NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />BOX PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY DEN MONITORING PERIOD <br />CA M I NE r IJI`;i'L E X YEAR MO DAY YEAR MO DAY <br />LocanoN ;.DEN FROM TO <br />_'Y KARQ. RECLAMATION MANAG <br />Form App ved. N <br />OMB No- 2040-0004 <br />M I NI]R <br />( SUBR JC ) <br />F - FINAL <br />DISCHARGE <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 <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER 1 rertif` under penal, or law that thi. da•umt-m and all attachments were <br />d <br />d TELEPHONE DATE <br /> prepart <br />un <br />er mt dinrlion or atpervisiun in accordance wilh a % mem designed - <br /> to a-um that qualified personnel pmperl% gather and esalualr the tnrormation <br /> submitted. Ravel nn nn in<pdn of the ite"at or pemms who manage the system. _ <br /> or those Wm,,ns directiH n+{wm.ihle for gathering the information. the informatiom - <br /> submitted 6. in the larm of mi knowledge and Wier. true, ticcurate. and complete. <br />J I <br /> I am aware that theft are signifinnt penalties for uhmiltin <br />false information SIGN RE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED <br />i g <br />, <br />including the possihilih td Fine and impri-nmeni for knowing .Ndatiiim. OF tER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br /> CODE <br />GVMMtNr5 ANU tAVLANAIION OF ANT VIOLATIONS (fierefence all attacnment8 nefe) - <br />T fi7,t01 -r-^ ='I1P. =t(}Y'F?. "[!NF` PR a:.TR F{I N.r T??- <br />EPA Form 3320-1 (Rev. N99) Previous edMorts may t1e Used. T h- Fs` a4-plug fbml. PAGE OF