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PERMITTEE NAME /ADDRESS (Include Facility Name /Location if Different) <br />NAME: <br />Moffat County Mining LLC <br />ADDRESS: <br />29515 Routt CR 27 <br />FREQUENCY <br />OF ANALYSIS <br />Oak Creek, CO 80467 -9704 <br />FACILITY: <br />WILLIAMS FORK MINE <br />LOCATION: <br />1030 CR 107 <br />VALUE <br />CRAIG, CO 81626 <br />ATTN Jerry Nettleton, Supv <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />000034142 003 -A <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />MM /DD/YYYY MM /DD/YYYY <br />4/1/2013 6/3012013 <br />Form Approved <br />OMB No 2040 -0004 <br />DMR Mailing ZIP CODE: 80467 -9704 <br />MINOR <br />No. 6 Mine to Williams Fork River <br />External Outfall <br />No Discharge EA <br />PARAMETER <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <br />QUANTITY OR LOADING <br />QUALITY OR CONCENTRATION <br />NO. <br />EX <br />FREQUENCY <br />OF ANALYSIS <br />SAMPLE <br />TYPE <br />VALUE <br />VALUE <br />UNITS <br />VALUE <br />VALUE <br />VALUE <br />UNITS <br />Oil and grease visual <br />840661 0 <br />Effluent Gross <br />SAMPLE <br />MEASUREMENT <br />to the best of my knowledge and belief true, accurate and complete I am aware that there are <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />* *. * ** <br />" + + " ** <br />/ (� <br />"+ <br />knowing violations <br />1/ <br />ARF\ Code <br />PERMIT <br />REQUIREMENT <br />" ** <br />Req. Mon. <br />INST MAX <br />Y =1,N =0 <br />" <br />" * " * ** <br />Twice Per <br />Month <br />VISUAL <br />NAME /TITLE PRINCIPAL EXECUTIVE OFFICER <br />I certify under penalty of law that this document and all attachments were prepared under my direction or <br />TELEPHONE <br />DATE <br />supervision in accordance with a system designed to assure that qualified personnel properly gather and <br />valuate the mformaeon submitted Based on my mqurry of the person or persons who manage the <br />system or thase persons directly responsible for gathering the mlormatron, the information submitted is <br />L.l•- <br />Cf �� L�-sr , �r-- <br />-V <br />CT -7 Z� <br />�� !x� <br />`f <br />to the best of my knowledge and belief true, accurate and complete I am aware that there are <br />SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR <br />sr gnrfwnt penalties for subm ttiog false information. including the possrbrbtyoffine and impnsonment for <br />/ Q ]C r <br />/ (� <br />TYPED OR PRINTED <br />knowing violations <br />AUTHORIZED AGENT <br />ARF\ Code <br />NUMBER <br />MMIDDIYYYY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />Oil and grease sample required If visible shee is observed Otrly sampling Instructions - I C 12, pg 11 <br />EPA Form 3320.1 (Rev.01 /06) Previous editions may be used. <br />05/08/2013 <br />Page 4 <br />