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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SVSTEM (NPDES)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />TYPED OR PRINTED I am aware That Nere am sign~carrc penalties for submitting false inlormation,
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here) ,
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<br />„xTHAL TO ~0~: OF TEST OHGAtiISrS, AND ATTACN PCDTE TOXICITY TEST 3EPO3T FOrkfl 10 DM3w COPIES OF ALL
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