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PERMITTEE NAME/ADDRESSpnd.bF.cl bryN=.?Le aria l/D(06e) <br />NAME <br />ADDRESS <br />LIL`l.X 187 <br />I G CO 81. <br />FACILITY 'JPER MINE <br />LOCATION I G CG 81 <br />%MOND G. DU BOIS, PRES/GM <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEMS /NPOESI <br />DISCHARGE MONITORING REPORT tDMRI <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO, I DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />OMB NO 2040-0004 <br />MINOR <br />(SUBR JC) <br />F - FINAL Mi <br />ACUTE WET TESTING FOR 017 A <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br />_ PERMIT if lfis rf # T ;-### 100.0001 <br /> REQUIREMENT MN VALUE `-' <br /> SAMPLE <br />.-- ; - MEASUREMENT <br />- <br />1 PERMIT <br />1 <br />000 <br />?tom###3E <br /># r;### <br />, I,. r <br />-4U7 <br />F <br />-'JFN T REQUIREMENT MN VALUE <br /> SAMPLE <br /> MEASUREMENT i <br /> PERMIT <br /> REQUIREMENT <br /> <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 />NAMEMTLE PRINCIPAL EXECUTIVE OWICER t mci y under pen. i' o taw ina this dOtmmUN and all attachmenu wtR <br />TELEPHONE <br />prepared under my dirtstbn or supervision In accordance with ¦ system dedgrard <br />DATE <br />to assert that quehfied personnel property gather and evaluate the Infcwmellon <br />submitted. Bawd M my Inquiry or the person or person who manage the system, <br />/ <br />of th <br />ersons dlrMy m <br />etnlble For <br />atherin <br />the Informatio <br />the I <br />rnruon -4 •ti <br />?? <br />se <br />f <br />p <br />p <br />g <br />g <br />o <br />n, <br />n <br />o <br />- <br />7 <br />t of m <br />lll <br />d I <br />th <br />b <br />tn <br />wled <br />nd b <br />lkf <br />tr <br />e <br />t <br />• '? <br />, l <br />b <br />t <br />d <br />l <br />t <br />% l <br />fu <br />m <br />s, <br />o <br />e <br />ea <br />y <br />u <br />ge a <br />e <br />. <br />u <br />, accura <br />e. an <br />comp <br />/ <br />e <br />e <br />e. <br />SIGNATURE OF /RINCr?AL EXECUTIVE <br />l <br />' l <br /> I am aware that there sew s <br />gNficanf Penalties for submhting false Information, <br />TYPED OR PRINTED Including fur p1rndblBy of fine ¦nd Imprisonment for Itnowing 0oledorea <br />I <br />OFFICER OR AUTHORIZED AGENT <br /> <br />CODE NUMNER <br /> <br />YEAR <br /> <br />MO <br /> <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Reforance aH attachments hare) <br />PORI• L-( Sfi - STATTSTICAL PQTNT rcc!-TVi?',TF W-4TCf4 Tc <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used Tt11, JS 3 4-paf'(IQtTTI. PAGE OF <br />-4 i