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PERMITTEE NAME/ADDRESS (include Farifih AameQarrotion if Dif(erent) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY wF+ D;Il?i£ C-I-JI`I=L l X MONITORING PERIOD <br />LOCATION YEAR MO DAY YEAR MO DAY <br />F N Co S le FROM TO <br />r KARO, RECLAMATIM' MANAGE <br />Form AppWired. is <br />OMB No. 2040.0004 <br />F? - FINAL <br />DSCHC' TO TRIBIHUBBE <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION N0, FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />? <br /> MEASUREMENT - <br /> PERMIT > a . - <br /> REQUIREMENT <br /> SAMPLE I <br />/ <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 -rnio under penalty orlaw that this document and all attachment%weir TELEPHONE TE <br /> rv <br />ar <br />nd <br />enisio <br />d <br />di <br />e <br />tio <br />o <br />w <br />i <br />o <br />d <br />ce with <br />st <br />d <br />si <br />ed DA <br /> p <br />p <br />p <br />t <br />u <br />er m% <br />r <br />c <br />n <br />r <br />n <br />n acc <br />r <br />an <br />a sy <br />e <br />gn <br />em , <br /> to t sure that qualified personnel properly gather and evaluate the information <br /> submitted. Hased on my inquin of the per ,nor persons wha manage the systrm. 11 , .t -1 <br />- _ <br />- <br /> or those persons directly responsible for gathering the information. the information <br />l <br />\ <br />? <br /> <br /> <br />submitted is, to the best ur <br />belief, true,accurate and complete. <br />I <br />-/ k- <br />i <br /> icant penalties <br />lam u•wre that them are sig ignifkant rnahias for .ubmiuing false information. SIGN A E OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />Including the pussihility of fine and imprisonment fur knowing siolationc. <br />OFFI R OR AUTHORIZED AGENT AREA <br />DE NUMBER <br />YEAR <br />MO <br />DAY <br />VVMMCM Ia AINIJ Cnrvsr?.er -" yr - , rrvverrvr?..r Iricrw crra.c are orsae.r rrrrcrrr, rrGrcj <br />EPA Form 3320.1 (Rev. 3/99) Previous editions may be used. 00 ` =' Thi% is a 4-Part form.