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PERMETTEE NAMEMDDRESS (yauidr rdtoeyM .WLarsriow VDWWwo) <br />NAME <br />ADDRESS <br />i3 it h 1 Ci i <br />iG GO 81 <br />FACILITY PER MINE <br />LOCATION G co 81 <br />7MOND G. DU BOIS, PRESIGM <br />NATIONAL POLLUTANT DISCHAROE ELIMINATION SYSTEM fNPOES/ <br />DISCHARGE MONITORING REPORT (D R) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEA MO DAY <br />FROM TO - <br />Form Approved. <br />OMB tdo 2040-0004 <br />MINOR <br />(SUUR JC) <br />F - FINAL MOtAI <br />RUNOFF /MINE WTR TO OAK GULCH <br />NOTE: Read imtruadom before camp let" this form. <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ### i; ' ..I? ### X It ; f sE , > <br />1 <br />1 <br />U is ' •I -' !?' l l' REQUIREMENT : niS T <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> 1 <br /> SAMPLE <br /> MEASUREMENT I, <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 />1 nrtalr under pens ly o ¦w that "document and all attachments were <br />NAME/TiTLE PRINCIPAL EXECUTIVE OFFICER rv TELEPHONE <br />prepamd under my directlon or supeisim In accordanre with a system de„itined <br />DATE <br />"- to etaure that quaMn*d personnel property ether and evaluate the Information <br />submitted. Based on my inquiry of the person or prsons who manage the system, r <br />M <br />tl <br />dbi <br />f <br />di <br />I <br />or <br />y rsspor <br />oss per a no <br />rec <br />t <br />or gathering the <br />nforsnallors, the information <br />submitted b <br />to the best of my keowledte and b.W <br />true <br />accurate <br />and com <br />l <br />t <br />- - <br />, <br />, <br />, <br />, <br />p <br />e <br />e. <br />' - - - I am await thu th- art sirnlr<ant penalfl ? for submittin <br />row Inrn,mstion <br />SIGNATURE OF ?RRICIPAL EXECUTIVE <br /> g <br />, AREA <br />TYPED OR PRINTED Iodudirg It,, poadbnity orr„e and Impw?n-i rot kr Joit OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference attechments hers) <br />!._E chi: T ill I T APP1 T FT) FOR i 0"' <br />i - •?t-? r?al??-I ' ?-t-a- --:; ter rl <br />- - - - - - - - - - - - - <br />EPA Form 3320-I (Rev 3'99) Previous editions may be used This Is.,a 4- .fonn- PAGE OF