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PERMITTEE NAME/ADDRESS Nnrludr Facility Name/!oration of Uiffrrrntr <br />NAME <br />ADDRESS <br />- GU <br />FACILITY <br />LOCATION _ f" (-j j <br />LANCE ,•, NE 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 Y R MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />M I NOF< <br />ZCMINE LiHNG TO CALAF-11 i -r DRAW <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY <br />OF SAMPLE <br /> EX YS <br />S TYPE <br /> ANAL <br />I <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> . <br /> PERMIT a o . _. <br /> REQUIREMENT 1'l T t i C r'l <br /> SAMPLE <br />_ <br /> MEASUREMENT <br /> PERMIT r w <br /> REQUIREMENT •?{? ''' <br /> SAMPLE <br /> MEASUREMENT <br /> ERMIT r _.; <br /> P <br />REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT - <br />-I REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE _ <br /> MEASUREMENT t <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .. a <br /> REQUIREMENT <br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER I certif) under penalty of law that this document and all attachments were TELEPHONE DATE <br /> prepared under nn direction or wupcrricion in accordance with a -tern designed = <br /> to assure that quAlifird penonnel prnprrh gather And esaluatr the inhumation - <br /> suhmitted. Rased an nn inquiry of the per.mt or per-as who manage the ystrm. ' <br />-- - or those persons dtrrth rrspwnsihle for gathering the information, the information <br />/ <br /> u <br />ate <br />and com <br />lete <br />wl <br />e <br />nd belief <br />t <br />u <br />c <br />r <br />k <br />d ' <br />- - <br />- i , <br />p <br />. <br />g <br />a <br />. <br />r <br />e. a <br />c <br />r <br />submitted ix. to the lira (j <br />nn <br />no <br />e SIGNATURE OF PRINCIPAL EXECUTIVE _ <br /> I am awum that there are significant penalties for submitting fal a information. AREA <br />TYPED OR PRINTED including the passibility of rim and impri-nment fur knowing siotations. OFFICER OR AUTHORIZED AGENT <br />- NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments nere) <br />APPLIED FOR 10YH,24HR PRECIP EVENT - SEE I.A <br />- I- C. 10, PG 20. 30 DA's' AVG IS HIGHEST MONTH <br />PAGE OF <br />This is <1-pifTt 1t flil <br />EPA Form 3320.1 (Rev, 3.99) Previous editions may be used,