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PERMITTEE NAMEJADDRESS Jncludr Facility N'amelacation if iNfferentl <br />NAME <br />ADDRESS <br />Box 670 <br />DEN ?p 8163T <br />FACILITY FGA MINE COMPLEX <br />LOCATION DEN CC! 8 j ,539 <br />Y KAR0, RECLAMATION 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 DA <br />FROM TO <br />Form Applpved A <br />OMB No. 2040-0004 <br />MINOR <br />(SUBR JC ) <br />F - FINAL Rch <br />17SCHG TO TRIB. SAGE CREEK <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 /> 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 I certify under penalty of law that this document and all attachmenit were <br />d <br />-I dir <br />tio <br />d <br />i <br />i <br />I <br />d <br />ith <br />t <br />d <br />l <br />d TELEPHONE DATE <br /> prepare <br />un <br />er m <br />ec <br />n or superv <br />n accor <br />ance w <br />a sys <br />s <br />on <br />em <br />gne <br />a <br /> la wore that qualified perwnnel prnperly gather and esaluete the Information <br /> submitted. Based on m? Inquin of the person or perwsn who manage the %ystem- <br /> or those pervom directly responsible rnr gathering the Information, the information <br /> whmilted h. to the brat of my knowledge and belief. true, accurate. and s mplete. <br />I am aware that there are significant penalties for submitting false information SIGNA RE OF PRINCIPAL EXECUTIVE V ( / <br /> <br />TYPED OR PRINTED , <br />including the possibility of fine and imprisonment for knowing riolation, <br />OF ICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />YEAR <br />MO <br />A <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />' :? :??..? =r! FRt.. '=lrl•,?la, 7?FJf? c:C.T-"';? i'-'i: <br />EPA Firm 3320-1 (Rev 3 99) Previous editions may be used. Ms:,-is a 4-Part form. PAGE OF