Laserfiche WebLink
PERMITTEE NAME/ADDRESS (Include Faciliiry.Same/Iacadon if Di Jaen) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS " <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY - ti rfT, c (Ui1"L:; MONITORING PERIOD <br />LOCATION ,s l .- YEAR MO DAY YEAR MO DAY <br />N C d H 1 TO <br />FROM <br />Y NIARU, RECLAMATION MANil ? <br />MINI <br />(Sul <br />F - <br />DSCI <br />Form App(Oved. 0 <br />OMB No-2040.0004 <br />NOTE- Raarl Inctriin inne hafnrp nmmniptlnn thin fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE 1 , <br /> MEASUREMENT <br />J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT i <br /> PERMIT .. , u <br /> REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT ?•. <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. d t <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />Z <br />? <br /> MEASUREMENT V <br /> PERMIT ; <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under prnally of law that thi%document and all attachmenh were <br />d <br />d TELEPHONE DATE <br /> prepare <br />un <br />er my direction or wpeni%ion in accordance with a .- %tem dealgned / <br /> <br />to aaaure that qualified personnel properly gather and rralmg,, the infoxmalion I <br /> wbmitted. lta ed on my inquin of the person or persunc %ho manage the system. i <br /> or thane prnor" directly mlpmmcible for gathering the information, the information ? <br /> ,uhmiued t., to the befit of mr knowledge and Wirt true, accurate. and compk4t. ?'( v <br /> 1 ern swam that there are.ignifkant <br />enalth? far submitti <br />false I <br />fo <br />tf SIGN URE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED p <br />ng <br />rma <br />om <br />n <br />mcluding the pon,ib Ii1.% or fine and impriwnment for knowing %ioiation. <br />O ICER OR AUTHORIZED AGENT <br />A <br /> <br />REA NUMBER <br />CODE <br /> <br /> <br />EAR <br /> <br /> <br />O <br /> <br /> <br />AY <br />-1- on artsV l,rIa11W 'furcr/ <br />Previous editions may be used. •?; i-i t : t <br />EPA Form 3320.1 (Rev. 3199) Y '}'111S+t$ a 4-pflTtlA(I71.