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PERMITTEENAME/ADDRESS rLuludr1ra;hr, ?::,,,. ;..:,r... nU.;h'•.'nh <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE 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 />RECEIVE- I-Ol.%orm Approved. <br />OMB No. 2040-0004 <br />JUL 2 .t 2009 _ <br />Division of Reclamation. <br />Mining and safety <br />,iNOTE: Read Instructions before completing this form. <br /> NO FREQUENCY SAMPLE <br /> <br />QUANTITY OR LOADING <br />OR CONCENTRATION <br />QUALITY . <br /> <br />X <br />OF <br />TYPE <br />PARAMETER <br />P E ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE I MAXIMUM UNITS <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> <br /> SAMPLE <br /> <br /> MEASUREMENT <br /> PERMIT <br />_ REQUIREMENT <br /> <br /> SAMPLE <br /> <br /> MEASUREMENT <br />PERMIT <br />- ?: REQUIREMENT <br /> <br />SAMPLE <br /> <br />MEASUREMENT <br /> <br />PERMIT <br />REQUIREMENT <br />- <br />, <br />SAMPLE <br /> <br />MEASUREMENT <br /> <br /> PERMIT <br />:i <br />REQUIREMENT <br /> SAMPLE <br /> <br /> MEASUREMENT 7, r <br /> PERMIT -; <br /> REQUIREMENT <br /> SAMPLE <br /> <br />MEASUREMENT - <br />PERMIT <br />- - REQUIREMENT <br />TELEPHONE <br />DATE <br />1 crn(fy under pen tlry „i law that this d.ku tern and all anachmenes were <br />EXECUTIVE OFFICER <br />NAME/TITLE PRINCIPAL <br />direction or >upenvtsrnn in accordance with a system designed ' -- <br />nder n <br />d <br />I i <br />u <br />n <br />prepare <br />n as, urc that qualified pcnonnel properly gather and esaluate the mtomutnon - ?' 7 ; <br />erson or person who manage the systcm. <br />n of the <br />p <br />suhmnt.d Based on my tngw <br />mfomtauon <br />information. th <br />h <br />e <br />e <br />Lit those persons directly respxuible for gathering t <br />acourate, and a,mplcte. SIGNATURE OF PRINCIPAL EXECUTIVE 1 7,, C'-75 <br />true <br />knowledge and Mlief <br />bc- <br />t of m <br />th 9 ? f <br /> , <br />. <br />s <br />y <br />submitted is, to <br />e <br />1 am awarc that there arc significant penalties for submitting false information, OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />E YEAR MO DAY <br />rs.nen no ootlJTCI'1 mrhuitne the nossihilaN of fine and imprisonment for knowing s'iolanons. COD <br />r rrcv v... - <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference allattachments here) ^? K <br />RE - <br />EPA Form 3320-1 (Rev. 3/99) Previous edibor,s rna, uEe us <br />PAGE OF