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PERMIT-TEE NAME.tADDRESS ,lnclude Facl in NameLucarrnn i/Lh(Terrnrl <br />NAME <br />COMPiiAY <br />ADDRESS NE <br />POX 459 <br />JRENCE co B1226 <br />FACIUTY <br />r R MINE <br />LOCATION, -iP.;.. DEN C-0 60460 <br />,"r;orst t/ C]nTTiC':' nr -%tKl MrIm <br />NATION.:. . PJLI-A.'. ,. riGc F. nr.:,l - •-.F ? - <br />DISCHARGE MONITORING REPORT (DMR, <br />PERMIT NUMBER DISCHARGE NUMBER _ F { fdAi_ JCKSN <br />MONITORING PERIOD VP R <br />YEAR MO DAY YEAR MO DAY <br />FROM TO X <br />IOTF• Ranrt Inatr++ntinna hatnra --latinn thlet fnrm <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br />i t SAMPLE ,ail sr <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT f9(t.{ I rL ('4 <br />T.l ! •='. SAMPLE i v t c ' <br /> MEASUREMENT <br /> PERMIT t•?f?taai# x, : =xbs? REPORT O E WICFf ;,it?tl <br />1= FL- 1 _ T ^rfi L ?5 v ALL i REQUIREMENT 30DA AV(;. , L N C i. ''1 ; l[3N TF-I <br />I ..FJlI G 1'. r' ` SAMPLE at- <br /> MEASUREMENT <br />I PERMIT H?F#fi?f t!. = 'k#### # 10 IIV .frt?i' <br />;UE N 1 GF G55 VALt ': REQUIREMENT <br />LOW, IN %CiNDU I T OF SAMPLE .- <br />" FIR'.! TREATMENT PLAN' MEASUREMENT <br />r• Cr PERMIT <br />-L '. r N i GNi]c;.[,- V,% .l _ REQUIREMENT ';V( <br /> SAMPLE <br />'? I SUAL MEASUREMENT <br />3 PERMIT tF t?S## R?.f"::1P. i F "'_ 3F#### ##### Y itit##31 t ?i rJ?.Cf J.`: _'t? <br />i r" f _ `JAL REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT I <br />I <br /> PERMIT <br /> REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I cettify under penalty „t law- that th s d-unt ni and all attachments were <br />d <br />d TELEPHONE DATE <br /> prepare <br />under my <br />uccnvn or supen,s,on in accordance -1111 a system desicned <br />Richard A. ?`unson <br />a1 assure that ualitied p`m)nncl pmp`riy gather and esaluate the informauun <br />s <br />submitted <br />Bawd on m <br />of ttk <br />erson or <br />in <br />uir <br />erxxu wh <br />mana <br />e the <br />'st <br />m <br /> <br />i <br />ic <br />id <br />t . <br />y <br />q <br />y <br />p <br />p <br />g <br />e <br />. <br />o <br />} <br />or ihase persons ducctly responsible for gathering the information <br />the mformalwn ? ?- - <br />+ <br />e y <br />an , <br />submitted is <br />to the best of m <br />know Ied <br />e and belief. tr <br />e <br />accur <br />t <br />nd <br />om <br />l <br />t 723 <br />?0 <br />9 y j j? 09 1 ? <br /> , <br />g <br />y <br />u <br />. <br />a <br />e, a <br />c <br />p <br />e <br />I ama-arc that there are <br />nificant <br />Ibr ntir <br />t <br />f <br />f <br />ti SIGNATURE OF PRINCIPAL EXECUTIVE 1 J <br /> <br />TYPED OR PRINTED e a <br />orma <br />sig <br />g <br />a <br />sc in <br />on. <br />including the pu sibility of f fiine and d imprisonment for (or know-+ng violations OFFICER OR AUTHORIZED AGENT AREA <br />NUMBER <br />YEAR <br />MO <br />DAY <br /> - CODE <br />L,UMMtrV I A AIVU CAI'LANAI IUIY Ur AIVT viuLAi iurVA (Hererence aii anacnmenis nere) <br />Er IP EVENT c1 Ir tr:rr TO BURDEN OF PROj3F <br />IN 48 <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 00322/ CiPI• • A A-P*li form PAGE OF <br />`3+I8 _