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PERMITTEE NAME/ADDRESS (Include Facifity Name/Location i/l)t,fJercml <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION 1,? !? E 1639 <br />v ',,FZO, RECLAMATION MANAGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />MINOR <br />(SULK <br />F - F <br />U 18 CF- <br />Form Approved. <br />OMB No. 2040-0004 <br />NOTE: Read Instructions beforeo6ompleting this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 r <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT i ... <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT Pt <br /> REQUIREMENT , <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT t:: r <br /> REQUIREMENT <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certif% under penalty of law that this document and all attachments were <br />prepared under m% direction or supersision in accordance with a system designed TELEPHONE DATE <br /> h, assure that qualified personnel properh gather and evaluate the information <br /> submitted. Based nn my inquiry of the person or persons who manage the system. <br />- <br />! <br /> or those persons direct], responsible for gathering the information, the information \ <br />- <br /> submilted h, to the best or m% knowledge and belief, true, accurate. and complete. <br /> I am aware that there are signiricanl penalties for submitting raise information SIGNATURE OF PRINCIPAL EXECUTIVE - 1- - <br />TYPED OR PRINTED . <br />including the possibilln of fine and imprisonment for knowing violations. OF CER OR AUTHORIZED AGENT AREA DE 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. i -? '• THIS; & 4-Part form.