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PERMITTEE NAMEIADDRESS (Include Facility Name/Location if Different)
<br />NAME i :i.. 7i I'.l1 i., is r: HDWA`' E::DAL MININC3
<br />ADDRESS I i`•S
<br />7--: 'STIE 207
<br />e 'u?L.z !?!CiO..D C.,0 f: "U it
<br />FACILITY ?t`•Id $'': i i' T?
<br />LOCATION €?::, 11 ??' I ; #_' tt'I t=}?
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<br />Form Approved.
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) OMB No. 2040-0004
<br />R) I
<br />?+ ?DIISCHARGE MONITORING REPORT y (D!11e [MSW?q?? r+
<br />PERMIT NUMBER DISCHARGE NUMBER F F I N AL u t
<br />SLIF?~'l CE- FlfNOF F TO TROUT MONITORING PERIOD
<br />YEAR MO DAY YEAR MO. DAY FROM TO ! ,.1' r 9s kfi i`•(Q D i 5C".1r;AR0F. I .?. I s4. } j
<br />NOTE: Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREQUENCY
<br />OF SAMPLE
<br /> EX TYPE
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<br />ALYSIS
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were TELEPHON E DATE
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<br />C prepared under my direction or supervision in accordance with a system designed
<br />to assure that qualified personnel properly gather and evaluate the information
<br />ersons who manage the system
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<br />or those persons directly responsible for gathering the information, the information
<br />submitted is, to the best of my knowledge and belief, true, accurate, and complete.
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<br />IGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED I am aware that there are significant penalties for submitting false information,
<br />including the of fine and imprisonment for knowing violations.
<br />g possibility g OFFICER OR AUTHORIZED AGENT AREA
<br />CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Rererence all attacnments nere)
<br />f'-lit T W*;L._, BE WAIVE£r FOR PRE-- FEVElk - EE 1. A. 2, P0. "i' FOR REQUIREMENTIS,
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. 001 9 / f 0Ttii'!7isi A *. &5fOrm. PAGE 10F
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