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PERMITTEE NAME/ADDRESS (/nelyde Faciliry Name/Lacalian if Digertmr)
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<br />NATIONAL POLLIJTANr DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMA)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />AXIMUM UNITS ANU.rs75
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<br />NAME/TITLE PRINCIPAL EXECUTVE OFFICER ICenity under penalty Mlaw Nal this tlocumemantl ell etlachmenis were
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<br />submleed Is , ro Ne Desk of my knovAedge end bellel, true, ecwrete, end complete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />l am aware Nat there ere signi~canl penalties for submitting lake inrormatlon,
<br />TYPED OR PRINTED Includin the osslbili of ens and im rlsonment for Mnowin vialetlons. OFFICER OR AUTHORRED AGENT
<br />NUMBER
<br />YEAR
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<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Relerence all attachmen4s here)
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<br />PA Form"332 =1 EV 3/99 -Previous eiJi{ions may be use ~ ` ` - "' ' ~ ' ~ ~ ~ ~ ' ° ~ ' THIS IS A 4-PART FORM PAGE OF
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