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PERMITTEE NAME/ADDRESS ilnelude Faeihi.v lame'l.,nrtion )/ Different) NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />NAME DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS <br />PERMIT NUMBER DISCHARGE NUMBER <br />FACILITY MONITORING PERIOD <br />LOCATION FROM YEAR MO DAY TO YEAR MO DAY <br />Form Approved. <br />OMB No. 2040-0004 <br />c avLsl^f I'+n I <br />F - FINAL <br />MINE DPAINACE TO G <br />Nf)TF• Ronrf Inctr..rfinnc Isnfnrn ?n -Inf:.sr. ffs:e f- <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> OF <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS EX ANALYSIS TYPE <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 /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalO of law that this document am] all attachments wen TELEPHONE DATE <br /> pn pared under ms direction or super.Won in accordance with a system designed <br /> to assure that qualifwd Prrwmnel prnperh gather and esaluate the information <br /> submitted. Barad on m% inquire of the person or permms whn manage the system, <br /> nr those pennns dir-ti % responsible for gathering the information, the information <br /> submitted t+, to the he.t or m? knowledge and belief. true, accurate, and complete. <br />1 am aware that th <br />re si <br />m <br />ific <br />nt <br />lti <br />f <br />h <br />i <br />i <br />p SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED <br />nAww.wewrTC huff cent • rresw. nr w e <br />a <br />a <br />pena <br />es <br />gn <br />w su <br />m <br />tl <br />ng ra <br />e information. <br />including the lwnsibilin of fine and imprisonment for knowing siolatium. <br />?..rs ,e,_?_..____ _.. ... <br />OFFICER OR AUTHORIZED AGENT <br />AREA NUMBER <br />CODE <br />YEAR <br />MO <br />DAY <br /> <br />ISMTT A REG <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part f0ml.