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PERMITTEE NAMEIADDRESS Unclndr Fariluv.Vame/!oration if Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />LOCATION r, S 1 FROM TO <br />'°ARO, RECLAMATION MANAG'i: <br />Form Approved. <br />0%16 r:c 2014F-0004 <br />MINI:, <br />( Sl)L ' <br />F <br />DSC!i; i-J i;?1iii?Rr+?z?r +rt?cfr <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREQUENCY SAMPLE <br /> <br />E OF <br />TYPE <br /> X ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT ) - V <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br />I <br /> MEASUREMENT i <br /> PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT L, (t? <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT <br />/ V ft _ <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE t <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE 1 / <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT '-"- ' <br /> SAMPLE <br /> MEASUREMENT i- _ <br /> PERMIT <br /> REQUIREMENT <br /> <br />NAMEMTLE PRINCIPAL EXECUTIVE OFFICER I certih under pemdly of law that this do rument and all attachments were <br />pnparrd under m) dircrlion or wpenision in accordance with a system designed TELEPHONE DATE <br /> <br />Dennis ,hews to -tire that qualified personnel properh gather and es aluate the information <br />j sabmitted. 8"-d on my inquin o f the person or persons who manage the system, <br />? <br />H I OtOg?84 . or those persom directh r-pomsible for gathering the Information, the Information j !' <br />rs wbmiurd is, to the beu of en, Lnowkdge and M•IkL true. accurate, and com=pute. 7 '. ' I <br /> 1 am aware that then arc signira-ant penalties her ohmitling false information SIGNATURE OF PRINQIPAL EXECUTIVE ' <br />TY ED R PRINTED . <br />including the possibility of fine and imprisonment far knowing siolalions. OFFICER OR AUT}fORIZED AGENT A <br /> <br />REA NUMBER <br />CODE <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />G1JMMtNIS ANU LAFLANAIIVN Ur ANT VIVLAIIVIVA <br />rracnmenrs nere/ <br />,111 <br />r_ ??-r ,•n ?: toot <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used.