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FERMITTEE NAMEIADDRESS (7.."FsrefyNwr?L«rfew ((D(QG.wu) NATIONAL POLLUTANT OISCHARGE ELIMINATION SYSTEM /INODES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />B0 X PERMIT NUMBER OISCHARGENUMISM <br />=:RSET 4? <br />FACILITY WORN CftM, _• MONITORING PERIOD <br />cL?`. c KN. h i''Jc YEAR MO DAY YEAR MO DAY <br />LOCATION ':RSET CC' *. FROM TO <br />IES T. COOPER, EXEC V. <br />Form Approved <br />OMB No 2040-0000 <br />MINOR <br />(SUER MH ) <br />F - FINAL LsUf-4 Is <br />SEDIMENT POND TO HUBBARD CREEK <br />NOTE: Read Inettuctione before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br /> <br />EX FRECUENcY <br />OF SAMPLE <br /> <br />TYPE <br /> [>< ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE ?. ' <br /> MEASUREMENT <br />- <br /> <br />PERMIT <br />## 3t#ii <br />I <br />?t##yF## <br />#ik##;s 7 <br />7 <br />7Z <br />h20:; ! REQUIREMENT II•dS T MAX <br />P`iCi(. r <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br />PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 rertllr under pen. ly o tsw that thh document and all attachments were <br />TELEPHONE <br />i <br />ti <br />vl <br />I <br />ith <br />t <br />d <br />i <br />i <br />DATE <br />on a super <br />> <br />on <br />• sys <br />prepare <br />under my d <br />rec <br />n accordance w <br />em des <br />gned <br />l <br />to more that qualified personnel property gatMr and eva <br />uate the Information _ <br />sobmltled. Bred on m Inquiry or the person or rsons who man <br />y Pe Ke the sptm,. <br />ibl <br />f <br /> <br />' <br />or those "room directly mpons <br />e <br />or gathering the Information, the Information <br />• I . i . <br />I <br />submitted b, to the best or my kmwkdge and beW, irw, accunle, and complete. , <br />SIGNATURE OF PRINCI?A EXECUTIVE <br />i <br /> 1 am aware that there are s <br />gnificant penalties rot aubmtlHng fate Information, ARE ? <br />TYPED OR PRINTED Inchading the possibility orflee and Imprisonment for kno.ing violation OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Referents eN attachments hers/ <br />Fr-T,LE SOLIDS L_MT APPLIED FOR '=iOYR, ^4HR r'PFCTP <br />EVENT-SEE PP 4-?. !. <br />EPA Form 3320-1 (Rev. 399) Previous edibons may be used TjIlS.1S.& 4 Plitt FOriTI. PAGE OF <br />J