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PERMffTEE NAME/ADDRESS Qnclude Faclllry NmnrlLoconon !!/Di$ereny
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<br />NATONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM MPDES) FOfm ApprOVed.
<br />DISCHARGE MONITORING REPORT (OMR~
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<br />~ OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
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<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON
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<br />PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
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<br /> POSSIBILRY OF FlNE AND IMPRISONMEM. BEE 19 U.S.C. § 1001 AND 33 U.S.C.
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<br />NUMBER
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Re/erence all attachments here)
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<br />EPA Form 332LL7 (OBA5) PreNous editions may not be used. (REPLACES EPA FORM Td0 WHICH MAY NOT BE USED.) PAGE OF
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