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PERMITTEE NAME/ADDRESS pelt&F rotm...eL. .n°n((Do.•wer) <br />NAME <br />ADDRESS (It <br />;IA CO 814 <br />FACILITY E NO. MINE <br />LOCATION [A CO 814;: <br />T w r. nn Am .MTwtr' Mr\r <br />NATIONAL POLLUTANT OISCHMOE ELIMINATION SYSTEM NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM TO <br />Form Approved. <br />OMB No 2040-0004 <br />MIN <br />csu <br />'F - <br />NOTE: Reed instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. <br />?E°UENCY <br />of <br />SAMPLE <br /> E <br />x <br />EX <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT ;k <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT 11 #x x.;., <br /> REQUIREMENT "' - <br /> <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT .- <br /> REQUIREMENT T'I.' i • MONTH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />[P <br /> REQUIREMENT MONTH <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT REPORT tF' )? N_,t # #4 <br />U REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br />* :• _r{ R. i <br />PERMIT <br />REQUIREMENT (y -i; :k,TR M• <br />NAMEMnE PRINCIPAL EXECUTIVE OFFICER t «ntly under penaly *(law that tMk document and all atlachmenb sere TELEPHONE <br />prepared ruder my direction itc -prt tdon In aerwrdan.e rIth • .ystent dedgned DATE <br />to assure that qua1111ed personnel property lather and evaluate the Informatlon <br />submitted. Baud on my ImI.Iry .f the person or persom rho man.le the system, <br />tr (hate persona dimcity mpornabtit for gathering the lnformatlon• the Information <br />submitted b, to the belt of my kmwledge and betlef, true, amtimle, and complete. - <br />SI <br />NATURE OF PAINCWAL EXECUTIVE <br /> I am a..- that there am dgNficant pensitles for robmitting false Informaton. O ARIA <br />TYPED OR PRINTED I.clutting the patdblHty of fine and Imprisonment for knowing Aoi.tlor.a OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ill affechmenrs hors) <br />_- ?r:• - - -;'f' Tom, ?.. 'r„ Ar-1'Rr••.11 -, ^Y W017T . <br />i <br />EPA Form 3320-1 (Rev 3199) Previous editions may be used This is a 4-pan orm. PAGE OF