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PERMITTEE NAME/ADDRESS Peeik k Fa W1yNw.WLer.r1w ((D(ffi-;) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTDM /NPDES) Form Approved. <br />NAME DISCHARGE MONITORING REPORT IDMRI OMB No 2040-0004 <br />ADDRESS _, . <br />) LOX 40, , PERMIT NUMBER ascHAr+oE NUMBER FINAL i---ELTA <br />IN I A - <br />FACILITY MONITORING PERIOD DEER TRL DTC OR UIVtlq TR I B <br />; I ? ?? 2' YEAR MO DAY YEAR MO DAY <br />LOCATION 'NIA co 61 FROM TO <br />J LL I AM A. BEAR JR.. MINE r NOTE: Read hutructiorto before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FAEOUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT s <br /> REQUIREMENT <br />Ll, ? <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />?x <br /> REQUIREMENT <br /> ,°iUt !Ti i <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT {if t: <br /> REQUIREMENT 7f?r, 11.1 ; F <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE - <br />1-IL-NI i-i MEASUREMENT <br />_t PERMIT REOOP' P?-..PORT r <br />C-, REQUIREMENT _30DA <br />t. SAMPLE s 2 <br /> MEASUREMENT <br />PERMIT ; <br />REQUIREMENT <br />NAMEmnE PRINCIPAL EXECUTIVE OFFICER 'm r<"y" of penalty ° I•. thal this drxumersl and all aaarhmenu.ere TELEPHONE DATE <br />pmpared under my directlon or super+tslon In aecerdanre with a system ddgned <br />to assure that qualified personnel Properly gather and eaaluale the Infnnnation <br />wtbmined. ee.e on my I"Wry of the person or pem,,ni, who -onset the System, <br />or those penore directly responAble for gathering the Inforrnetlen, the Info-d- - <br />submitted h <br />to the b"( of my krsowladee and beNef <br />trot <br />amrnte <br />and com <br />l <br />r <br />, <br />, <br />, <br />, <br />p <br />e <br />. <br />I am ..ayes that there are significant Penalties for submitting falm Information <br />SIGNATURE OF PRINCNAL EXECUTIVE <br />TYPED OR PRINTED , <br />lncludlne lhr posdblllty of floe and Imprlfonmenl for knowing violauon>_ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Roferenc• ill attachments here/ <br />EPA Form 3320-1 (Rev 3!99) Previous editions may be used This IS a 4-parr form. PAGE OF