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PERMITTEE NAME/ADDRESS(Y-&&i«+aryNw?L«eii n(fD(f-i) <br />NAME <br />ADDRESS <br />BOX 433 <br />HAUNIA CO <br />FACILITY _ 1'E NO. c M I NE <br />LOCATION "4 X A. C 0 <br />I TAM AN AI=AR . IR M T NF <br />NATIONAL POLLLITANT DISCHARGE ELIMINATION SYSTEM NPDES/ <br />DISCHARGE MONITORING REPORT /O R) <br />PERMIT NUMBER DISCHAAOE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />S I =: FROM TO <br />Mi _ <br />Form Approved <br />OMB No 2040-0004 <br />M <br />( INOR <br />SUBR MH ) <br />F - FINAL <br /> 'DEER TRL_ DTC OR UNP <br />NOTE: Read h»tructione before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, <br /> <br />EX FREOUENCY <br />OF SAMPLE <br /> <br />Y <br /> ANALYSIS PE <br />T <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 ##3E#i?# p r:•##! <br />,. L i 1` REQUIREMENT 0 D! A V G i)r'• i l hi ?•. MONTH <br />r SAMPLE <br /> MEASUREMENT <br /> PERMIT (E# ;;i? Iv__ - ?R <br />S REQUIREMENT ODA AVt: i`1X ?i0 N H <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT IN, <br />-? <br /> REQUIREMENT 1( i" -- <br />(!`i 1 SAMPLE <br />TREA 1 I MEASUREMENT <br /> PERMIT PEPC]RT I+,;_. _. ?•el <br />S VA REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMI T: tr x <br /> REQUIREMENT <br />AME/TITLE PRINCIPAL EXECUTIVE OFFICER ' cert'ly " Pe". ty .w lh.t w h dorvme"t .lid all ¦ItKhmente weR TELEPHONE DATE <br />N prepared under my direellon w ep "vIWcm In a rdanct w11h • SyStem designed <br /> to amum that quaMfied personnel property gather and evaluate Iht Information <br /> ambm fitted. seed en my Inquiry *(the peron or persons ho manage the system, <br /> K those person directly respomible For gathering the Information, live Inrorrnallon <br /> Submitted b, to the best of me knowledge and belief, true, accurate, and cornplHe. <br />I am <br />vrar th <br />re Si <br />nificant <br />enalti <br />f <br />bmltdn <br />fals <br />Inr <br />t th <br />r <br />ti <br />SIGNATURE OF PRINCIPAL EXECUTIVE , <br /> g <br />a <br />a <br />em a <br />p <br />es <br />o <br />e <br />g <br />e <br />or a <br />ca, <br />TYPED OR PRINTED Including the pos lblBty of line and Imprtsactmtml for kno.lnt Ndatiom OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference aM attachments hare) <br />SF Ai?l <br />T l 1 i3URr'! 01 'f?DC) <br />This IS <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used. . a 4-part form PAGE OF