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PERMITTEE NAME/ADDRESS(7m&&For0tyNo-Wf. rrtan((DOWwu) <br />NAME <br />ADDRESS <br />0. BOX 187 <br />? G CO 816 <br />FACILITY PER MINE <br />LOCATION G CO 816 <br />!MOND G. DU BOIS, PRES/GM <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 <br />Form Approved <br />OMB No 2040-0004 <br />NOTE: Read Inetructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREQUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ####d iF#3t### _ 5 '' r-?tom s _ Ji. li?JST rl <br /> REQUIREMENT MINIMUM MAX I I1Lw! <br /> SAMPLE ;_ .. <br /> MEASUREMENT <br /> PERMIT # a ## II # ##aE cr ^ =iF=-t I " 1J. a AB <br /> <br />C`F _ REQUIREMENT <br />9 <br />v <br />SODA A'.''? <br />t', i L_ r' f <br />i`lia4 rl <br />t- .: - SAMPLE <br /> MEASUREMENT <br />t PERMIT ####, <br />RAB <br /> REQUIREMENT : hIS f MAX GIa,!T <br /> SAMPLE <br />p MEASUREMENT <br /> PERMIT REPDR L)F( -. !? if . <br /> REQUIREMENT -1drDA_4+Y - --0tC I L Y MX <br />_ SAMPLE ' <br /> MEASUREMENT <br /> PERMIT t .. ? REPORT r t.. <br /> REQUIREMENT AVG 1-.,',IL MX <br /> SAMPLE <br /> MEASUREMENT <br /> <br />.t <br />PERMIT <br />t= 'LJRT <br />ra' ,? <br />7 .. <br />#ai <br /> REQUIREMENT MAX MONTH <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER l rertit7 Y er pen. t7 0 la. that this d-wni and all atlochmatHe were <br />TELEPHONE <br />prepared under m7 direction or supn-vl>tort I. accordance with ¦ system designed <br />DATE <br />to meune that quatifled personnel Properly gather and evaluate the Informatbn <br />submitted <br />based on m7 Inqulr7 *(the person or persons who manage the system <br />, <br />. <br />- at those persons directly rsJponslble for gathering the Information, the Infofwntlon <br />to the best of m7 knowled <br />e and bellef <br />true <br />sccunle <br />i submitted h <br />and com <br />lete <br />• - i <br />g <br />. <br />. <br />. <br />p <br />. i <br />, <br />SIGNATURE OF PRINCIPAL EXECUTIVE <br />fk <br /> 1 am swam that theft art slgnl <br />ant pmahles for submitting fallow Informsdon, <br />TYPED OR PRINTED Including the Possibility of nne and Imprisonment nor knowing rlolatlorn. <br />h OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rereronc• an attachments are, <br />RLE SOLIDS LIMIT APPLIED FOR =10YR,24HR PRECIP EVENT- <br />MON I TOR I N l T E T? ) <br />1.ihi7Eal PPRTnn RFPfj; -' <br />!: TI16s? L'P?`r4n?1. PAGE OF <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used