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PERMIITEE NAME/ADDRESS (include Fatilu), A'ame/l rtmon if Different) <br />NAME <br />ADDRESS <br />)EN <: D 8; 63 <br />FACILITY <br />CA MIr:F- t ;vX <br />LOCATION ca 8 163 <br />•K•ARO: RECLAMATIM4 MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Applrved. A <br />OMB No. 2040-0004 <br />MIN[ <br />( Sul <br />F - <br />Dtsc <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY 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 />ME <br />M <br /> ASURE <br />ENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT j- ?-, <br /> PERMIT # i-r _, <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT 4 <br /> PERMIT <br /> REQUIREMENT i)e % i I 'r X <br /> SAMPLE _ l <br /> <br />ME <br />REME <br />T <br />S ^ <br /> A <br />U <br />N <br /> PERMIT <br /> REQUIREMENT - ,r <br />NAMEfrITLE PRINCIPAL EXECUTIVE OFFICER I , rlif% under penalp ,d law [hilt thisdocument and all attachmenL%were <br />red und <br />ttion or <br />r <br />r <br />dir <br />n'ision I <br />o <br />d <br />with <br />t <br />d <br />i <br />d ! TELEPHONE DATE <br /> p <br />epa <br />e <br />m) <br />e <br />wpe <br />n acc <br />r <br />ance <br />a sys <br />em <br />gne <br />es , <br /> In assure that qualified personnel properi? gather and evaluate the information <br /> submitted. Rased on my inquire of thr persm or persom whit manage the system, _ <br /> or those perwm directll responsible for gathering the information. the information <br />t <br /> submitted is, to the hest of m% knowledge and belief. trot, accurate. and complete. <br /> I am aware that there are significant Penalties for suhmilljng false information SIGNATU OF PRINCIPAL EXECUTIVE -? <br />TYPED OR PRINTED . <br />including the FHmibilits of fine and imprisonment for knowing violation. OFFICE OR AUTHORIZED AGENT AREDA NUMBER YEAR MID DAY <br />Tit\v en rt_vtrrh t tvty yr rstvT viwum[tvno InafatanUr an auauunanw nave/ <br />!IF <br />EPA Form 3320-1 (Rev. 3189) Previous editions may be used. 00157 'Mis is a 4-parff irm.