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PERMITTEE NAME/ADDRESS (Include Facfliry Name/Location ijDi,Q4ren1) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />r; PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />CA t-UHF-L-EX YEAR MO OAY YEAR MO DAY <br />LOCATION ,EN C 0 81 •` FROM TO <br />r' KARO, RECLAMATION MANAG;- <br />Form Apprved a <br />OMB No. 2040-0004 <br />MINOR <br />(SUBR JC) <br />F - FINAL <br />t?SCHO TO TH <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY <br />OF SAMPLE <br /> EX TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE / <br /> MEASUREMENT O J <br /> PERMIT <br /> REQUIREMENT - <br /> SAMPLE II <br /> MEASUREMENT <br /> PERMIT <br />r; , <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT 1 <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT `., <br /> PERMIT > <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREME <br />T I <br /> N <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />rJ ( <br />{ <br /> MEASUREMENT ; ! yr <br /> PERMIT y . _ <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I crrtif7 under penalll ,f lae that Ihi%ducument and all attachment' were <br />ed <br />de <br />di <br />ecti <br />e <br />kir <br />with <br />'t <br />d <br />l <br />i <br />d <br />d . <br />. TELEPHONE DATE <br /> prepar <br />un <br />r my <br />r <br />on or'up <br />n <br />a, <br />n accor <br />ance <br />a'I <br />em <br />e' <br />gne <br /> to a' rr that qualified Per'onnel properfl gather and e'altrale the information <br /> 'ubmilted. Ra'ed an mI inquin of the person or pre nc who manage the'I'teau <br />w Iho'e person' dimcUl rr.ponsiblr for gathrring the information. the information <br /> 'uhmithd h, to the hra of m) kw-Irdge and belief. true, accurate. and avmplete. <br />I <br />wa <br />th <br />t the <br />e a <br />%i <br />iriel <br />t <br />e <br />ltk' fo <br />s <br />b <br />itti <br />f <br />l <br />i <br />f <br />tio <br />SIGNA <br />RE OF PRINCIPAL EXECUTIVE L/ <br />' <br />TYPED OR PRINTED am a <br />re <br />a <br />r <br />m <br />n <br />na <br />u <br />m <br />ng <br />a <br />w <br />orma <br />a. <br />gn <br />p <br />r <br />n <br />including the poslbilin of rim and impriwnment for knowing'iolatiom. CE <br />OF R OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous edfions may be used Thiti is a 4-part POnn. PAGE OF