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PERMITTEE NAMEIADDRESSpnaYiF«vbryNw?L-sti tfD( Wwd) <br />NAME <br />ADDRESS <br />BOX 483 <br />iA C[ <br />FACILITY E R10. 2 MINE <br />LOCATION I A C r <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM /NPOESI <br />DISCHARGE MONITORING REPORT (OMR) <br />PERMIT NUMBER DISCHAAGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved <br />UMB No. 2040-0004 <br />( 5i <br />F - <br />SRi <br />NOTE: Read Instructlom before completing this form. <br /> NO. FREQUENCY SAMPLE <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION OF <br /> EX TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS ANALYSIS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT # ?.. <br /> REQUIREMENT i?iY. <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ., REP OR I ?f' <br /> REQUIREMENT LEA I I..Y +": l? a I <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT -'1 3000 <br /> REQUIREMENT 30DA <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT kN r t "n:"?"Ini <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT - n? <br />3 i:r .. #?t x <br /> REQUIREMENT ?L'?r, hVi <br /> SAMPLE <br /> MEASUREMENT <br />r <br /> PERMIT N -PUi? <br />. 1-1 A 13 <br /> REQUIREMENT R M1 .: <br />I <br />TITLE PRINCIPAL EXECUTIVE OFFICER I o`n'ly under pen. ly ° ¦. that th is d°`°menl and .u uu`hmenu we" <br />d TELEPHONE DATE <br />NAME/ prepared under my direetlon or mperelfon In aroordanee »Ith • system designe <br /> to ..tire that quaMned personnel properly gather and eraluale the Inrorenation <br /> sobmalied. Bred on m7 irpuiry of the person or pervom he manage the syslern, <br /> or thew persme directly resprmdbk for gathering the Information, the Information <br /> submlmd 6. to the bet *(my ?nor ledge and bellef, true, .Doom`, and complNe. <br />F PRINCIPAL EXECUTIVE <br />A <br /> i am a.tire that there .re signirkaM pendNe ror aebmitting rake, info motion, SIGN <br />TURE O ARIA <br />N <br />M <br />E <br />AR <br />MO <br />DAY <br />TYPED OR PRINTED Induding the poadbtllly o( n- and imprisonment For Ano.ing rielatlotx OFFICER OR AUTHORIZED AGENT U <br />B <br />R <br />CODE YE <br />COMMENTS AND EXPLANATION OF ANY VIOLA I1UN5 /Rorarlnce M orracnments neraf <br />P4=^'ri ,rF!'IT I A iMED Tr C( ATM PPPRnVET) ICY Wa--,)- <br />, - PAGE OF <br />EpA Form 3320-1 +Rev 199) Previous editions may be used This is a 4-Part form