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PERMITTEE P - -I.; NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (AIDES) Form Approved <br /> F acr/ffy ,"amr/•• 1 :.;1. I DISCHARGE MONITORING REPORT DMR <br /> ( ) OMB No. 2000-0015 <br /> CE ---!1— ——— (2-/6) (17-191 <br /> ADDR —. <br /> Es• P. O. LSO iJJ: --------- <br /> I <br /> %J <br /> PERMIT NUMBER IDISCHARGE NUMBER <br /> ---- L A K E'Ov'00 D, CCILi,13IUO 30215 -------- <br /> ----- ————————— MONITORING PERIOD <br /> FA4;-1L!IY-- ,a _------ YEAR MO DAV YEAR MO DAY <br /> Gold Eagle Mine FROM j TO <br /> LOCATION ' <br /> ---- --------- <br /> 120-2111 f22-2.1) (24-25i (2e-27) (28-29) fm-ij) NOTE: Read instructions before completing this form. <br /> (3 Card Only) QUANTITY OR LOADING (4 Card Only) QUALITY OR CONCENTRATION <br /> PARAMETER (46-53) (54-61) (38-05) (46-53) (546/) Np, FR EOOUFENcr SAMPLE <br /> (32 37) EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS><7� 6263) (6468) (69-70) <br /> SAMPLE <br /> MEASUREMENT <br /> i PERMIT <br /> t+•)rl'��: REQUIREMENT <br /> SAMPLE <br /> t MEASUREMENT <br /> t F i Pi 14 1 1 PERM IT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> I A ( t:` 'i ) PERMIT <br /> REQUIREMENT _ <br /> SAMPLE <br /> ,�(I( , 1 i ( • MEASUREMENT <br /> PERMIT <br /> REQUIREMENT .. <br /> SAMPLE <br /> MEASUREMENT I s <br /> 1 <br /> ' PERMIT ' <br /> REQUIREMENT <br /> SAMPLE <br /> f MEASUREMENT <br /> PERMIT 1. <br /> 3 REQUIREMENT .. <br /> SAMPLE <br /> MEASUREMENT <br /> 1. PERMIT <br /> REQUIREMENT <br /> NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED TELEPHONE D A T E <br /> AND AM FAMILIAR WITH THE INFORMATION SUBMITTED HEREIN, AND BASED — <br /> ON MY INOUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTED INFORMATION <br /> IS TRUE. ACCURATE AND COMPLETE I AM AWARE THAT THERE ARE SIG- <br /> NWICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING I YY _ t I •'t.( <br /> (l' THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 16 U.S.C. 4 1001 AND I -� <br /> '-- '•��4`^' - a-`"•"' -)'' -:'�t-i i •. <br /> 33 USC 41319. (Penalties under these statutes may include fines up to ElO,(1!)0 SIGNATURE OF PRINCIPAL EXECUTIVE <br /> � <br /> TYPED OR PRINTED and or maximum onprisonment of hetueen 6 months and 5 years.) OFFICER OR AUTHORIZED AGENT ATFEA NUMBER YEAR MO DAY <br /> CODE <br /> COMMENT AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />:PA Form 3320-1 (F. 0-79) PREVIOUS EDITION TO BE USED (REPLACES EPA FORM WHICH MAY NOT BE USED.) OF <br /> UNTIL SUPPLY IS EXHAUSTED <br />