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PERMITTEE NAME/ADDRESS(7-*,&Faddbcry N-a?Le wl-(fD(fl o) <br />NAME <br />ADDRESS r:. <br />box <br />-RSET CO H] <br />FACILITY QRN CI . ? & CPK MINES <br />LOCATION . RSET 91 <br />!-I;= q T c flf1P PR, 'r`- X F(: V P. <br />NATIONAL POLLUTANT 04SCHAROE ELIMINATION SYSTEWI /rNPOES1 <br />DISCHARGE MONITORING REPORT (DMRJ <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR M DAY YEAR M D 4Y <br />43-4 FROM - I _j TO <br />Form Approved e <br />MINOR _Mo 2040-000¢ <br />(SUBR <br />1 - Fl. <br />SURFACL <br />NOTE: Road Irntrvedone before completing thle Poem. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FREGUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />i LUF_N- U.?`? REQUIREMENT MINi!`1,_ AXIMV!r! iOR <br /> <br />i . t 13T 77717- _ SAMPLE r ;;, ..... <br />= ?ENDFI`• MEASUREMENT <br />' i PERMIT <br />- ) V^1 !ji REQUIREMENT A`.' : . <br />„ + . SAMPLE . <br /> MEASUREMENT <br />Q ! > PERMIT ... i _... _ . <br />. .. <br />E <br />i_.. _ REQUIREMENT <br />:+.t. SAMPLE <br />r1 ) MEASUREMENT <br />' "x145 1 t PERMIT , <br />U1=NT REQUIREMENT 30DA A?, : L Y -' ? <br />An 17; , SAMPLE _ <br /> MEASUREMENT <br />- PERMIT <br />-: k C c -- L'..)' REQUIREMENT !FIST <br /> SAMPLE <br /> MEASUREMENT <br />U PERMIT z <br />-LU 1 <br />i i I ;-i_':?S VALUE <br />REQUIREMENT <br />:30DA F•.. <br />LY i`i! <br />i"" <br />r' <br /> SAMPLE 4 <br /> MEASUREMENT <br /> PERMIT t•. <br /> REQUIREMENT L: , t ! X <br />NAMEMnE PRINCIPAL EXECUTIVE OFFICER pt re «parny rtd ° a eader pe"' di y o rer htlon. orIh* <br />euUP <br /> <br />m. r <br />N document and au a with a nta a]st were <br />m n doltned <br />rvMow in aeeo rd . txe with a <br /> <br />TELEPHONE <br /> <br />DATE <br /> Ia "u" that qualified P-nnel P.operi7 tattier and evaluate the Information <br />mbnrtted. Need on me Inquiry of the Perron or peeaoew who manete the syetem. - <br /> ?) + ?' ` r <br />/ <br />? or those persona diteety n Poadble for gathering the Information, the Inform¦tion y 7 <br />(-(. ? t : <br />_ ?• .. tubmllted Is. to the bet of m7 knowledge and IwW. Uoe, accvnte, and complete. <br />Nfi <br />l <br />fi SIONATURE OF PRINCIPAL EXECUTIVE <br /> <br /> <br />TYPED OR PRINTED <br />?m aware Ua1 tere art a <br />t <br />nwt pmattle for wbmll <br />M falw In(orettatleu. <br />Incnwtng the poodbtfitf or fine and Impriaoament for knowing .tetatlom <br /> <br />OFFICER OR AUTHORIZED AGENT <br />AREA <br />CODE NUMEIER <br /> <br />YEAR <br /> <br />MO i4l <br /> <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference sI/ attachments here) <br />% <br />FA1 !_E SOL TDS LMT APPL_IFP FOR -'=10, 24HR PRFCIP FV NT; <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan form. PAGE OF