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PERMITTEE NAME/ADDRESS !Include Paeilhy A'ame/Loralion iJDifferentl <br />NAME <br />ADDRESS <br />VOX 670 <br />CO 8163 <br />FACILITY MINE CE31"IRLEX <br />LOCATION :O 6163 <br />i:7iRO t R EC LA!IA T I ON MANAQER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No. 2040-0004 <br />• <br />IS <br />. <br />UISCtiFtFi.vE r41 :3A'G'E CREEK <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 /> 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 <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 />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER 1- rtiR under penulq or law that this dtwumrnt and all allachmenls were <br />d under n <br />dir <br />tio <br />o <br />r <br />cisu <br />i <br />a <br />-l <br />with <br />o <br />m d <br />i <br />d TELEPHONE DATE <br /> p <br />p <br />epare <br />ec <br />n <br />r super <br />m <br />n <br />ct <br />art a <br />n . <br />e <br />gne <br />es <br /> t- assure that yuAined prrwnnel properly gather and esaluate the informaUmt <br /> submitted. Rased on my inquiry of the perwrn or Imams who manage the syslem. <br /> nr them persom dir"tis resfaursible for galhering the information, the information - <br /> -britillad is. It, the tw•st or m, knowledge and belief. true. accurate. and _luplele. <br />1 am aware that therr are significant penaltio for suhmlttinµ false information. $IGNATUkiE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />including the p-ibilitq of fine and imprisonment for knowing siolutions. <br />OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> CODE <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320.1 (Rev. 3198) Previous editions may be used. J 0