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PERMITTEE NAME/ADDRESS /Include Facititr.V'ame/Location if Afferent) <br />NAME <br />ADDRESS <br />co 81634 <br />FACILITY , MINE C ONPL E X <br />LOCATION ,,FIB C f? t x,34 <br />KAF 1-3, RECL.ANATT[IN MAN. AGER <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />A <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Apprpvod. <br />OMB No 20-40-0004 <br />MI <br />F -. <br />OSCH- TU FRIB/GRASSY CREEK <br />NOTE- RPat1 Inctrttrtinnc hafnrn rmmnlotinn thin form <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> OF <br /> <br />AVERAGE <br />MAXIMUM <br />UNITS <br />MINIMUM <br />AVERAGE <br />MAXIMUM <br />UNITS EX ANALYSIS TYPE <br /> SAMPLE <br />l <br />F <br />i <br /> MEASUREMENT _ <br />. Q l <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br />I <br />1L <br />J <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE / <br /> <br />MEASUREMENT II <br />? <br />?1 % C> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE , <br /> <br />--vc: MEASUREMENT <br />v <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT J <br /> PERMIT <br /> REQUIREMENT r <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I ceriiry undo, Ix•nalq or law thm this document and all attachmenh we" <br />d TELEPHONE DATE <br /> prepare <br />under m% dir anon or supeni,ion in accordance with a .stem designed , <br /> to assure that qualified personnel properly gather and es aluate the inrormation <br />suhmitted <br />sed o <br />B <br />s i <br />r th <br />i _ <br /> . <br />a <br />n m <br />nqu <br />re o <br />e person or prrwns who manage the stem, <br /> or th.ne penoms direct] re <br />? sp.insihlr for gathering the information. the information <br /> submitted is- to the hest of rn knowledge and belief. true, accurate, and complete. <br />I am aware shot there are si <br />nificant <br />n <br />lties fo <br />h <br />i <br />ti <br />f <br />l <br />i <br />f <br />i <br />SIGNA RE OF PRINCIPAL EXECUTIVE t.y- <br />- 1 <br />?J <br /> <br />TYPED OR PRINTED g <br />pe <br />a <br />r su <br />m <br />t <br />ng <br />a <br />se <br />n <br />ormat <br />on, <br />including the msihiliq of fine and imprisonment for knowin <br />p g siolations <br />OF ER OR AUTHORIZED AGENT g NUMBER YEAR MQ DAY <br /> <br /> <br />r- c1 <br />.PA Form 3320-1 (Rev. 349) Previous editions may be used. ;, t 4 !;1 ?• , ' -This' is S 4-part' fOfm.