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PERMITTEE NAME/ADDRESS i(nclade F'arilifr ation if Diffe rent) <br /> <br />CENV Ep NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) Form OMB No. 204D Approved. <br />-0004 <br />NAME qE DISCHARGE MONITORING REPORT (DMR) <br />ADDRESS n <br />9 <br /> L 2?? <br /> )?iL l? PERMIT NUMBER DISCHARGE NUMBER <br /> <br />FACILITY ;,+,;Slotl ut ReClamaUon, MONITORING PERIOD i u t 'X53,"' `? ` <br /> Mining and Safety YEAR MO DAY <br />YEARMO DAY <br />LOCATION FROM TO <br /> NOTE: Read Instructions before completing this form. <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO, FREOUENCY SAMPLE <br /> <br />EX OF <br />TYPE <br /> ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <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 aertif) under penalty of Ian lhnt thi+daavmanl and all atwchment+ wrrr <br />r <br />dir <br />cti <br />i <br />i <br />d <br />d <br />i <br />i <br />d <br />h <br />d <br />i <br />d TELEPHONE <br /> <br />TELEPHONE DATE <br /> prepare <br />un <br />my <br />on or supen <br />on <br />n accor <br />ance w <br />a -tem <br />e <br />e <br />s <br />t <br />e <br />gne <br />' <br /> a+sure that qualm d rwr+onnd properly gather and rsaluute the <br />information <br /> suhmitled. Razed on my inquire of the [wean or per+ons who manage the +y.stem. <br />i <br />' <br /> or If,.- persons dirret <br />? rest o <br />ihle for gathering the information. the information <br /> submitted is, to the best of m7 knowledge and belief. true. aarurate, and completr. <br /> 1 am aware that there are significant penalties for submittin <br />rale- information SIGNATURE OF PRINCIPAL EXECUTIVE <br />TYPED OR PRINTED g <br />, <br />including the p-ihflity of Fine and imprisonment for knowing +iolations. OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3199) Previous editions may be used. This is a 4-part fort!!.