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PERMITTEE NAME/ADDRESS (Include Facilifp r\nme/Lnrefion if tfifferent) <br />NAME <br />ADDRESS - i " <br />BUS, ' 70 <br />OEN n 81bu <br />FACILITY ?.4 F, f F._ _I` `?` <br />LOCATION DEI`J {? 3163 <br />V =?Rv 0, RECLAMATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO L_ I <br />Form Approved. <br />OMB No. 2040-0004 <br />Pei I NOR <br />(SUBR JC <br />F - FINA <br />DSCHt3 TO <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO• FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE / <br /> MEASUREMENT <br />?J <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - ?- <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />C J ? 7 <br /> MEASUREMENT I - i <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ( rI i <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE ' <br /> MEASUREMENT f S <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certifi under perud1% of law that this dr.vmcni and all attachments were <br />r <br />s di <br />i <br />d <br />d <br />ti <br />i <br />i <br />d <br />i <br />h <br />d <br />i TELEPHONE DATE <br /> Prepa <br />un <br />er m. <br />rec <br />on or superv <br />on <br />n accor <br />a -ienu <br />e <br />s <br />ance w <br />t <br />es <br />gned i <br /> W assure that quali(ed personnel properly gather and evaluate the information i <br /> submitted. Based on my inquiry of the person or persons who manage the system, <br />' ` <br /> or Iho" persons dirceii, msp n <br />,ihlc for gathering the information. the information - <br /> submitted is, to the hest of I <br />knowledge and heiief, true, accurate, and complele t <br />! ` <br /> . <br />. <br />I am .ware that them arc si <br />nifaam <br />lti <br />itti <br />en <br />s fo <br />s <br />b <br />f <br />lse i <br />fo <br />ati <br />SIGNAT RE OF PRINCIPAL EXECUTIVE J , <br />`-J <br />TYPED OR PRINTED g <br />p <br />a <br />e <br />r <br />u <br />m <br />ng <br />a <br />on. <br />n <br />rm <br />including the pKsibilit) of fine and imprisonment for knowing siolations. OFF ER OR AUTHORIZED AGENT AREA NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. nis is a 4-part form. PAGE OF