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<br />NATIONAL POLLUTANT DISCHANOE ELIMINATION SYSTEM lNPDES)
<br />DISCHARGE MONfTORINO REPORT lOMR/
<br />11-161 717-191
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM 't '! ~ / I TO '' '.
<br />!16111 711-131 l1F15/ !1617/ 11B-29/ !3637/
<br />Form Approved.
<br />-~~ ~ - - - OMB~No:2040-0004
<br />T - ., , , ~ Approve! eicpirea OS-31-98
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<br />NAME/TTTLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY E%AMINED AND TELEPHONE DATE
<br /> AM FAMILIAR NATH THE INFORMATION SUBMITTED HEREIN; AND BASED ON
<br /> MY INQUIRY OF THOSE IMOIVIDUALS IMMEDIATELY RESPONSIBLE FOR
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<br />.Icha rc I'LI~~$ OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
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<br />SIONIRCANT PENALTIES FOR SUBMITTING fALSE INFORMATION
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<br />THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE Ie U.S.C.l1001 AND 3a
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<br />EpA Form 3320-1 108.951 Previous editions mey be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.1 ~ ~ „„ ~ / ~ C;; ~ ~ _ I ,~ ~ PAGE ~ OF
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