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<br />NATONAL POLLUTMT OISCHMOE ELIMINATION SYSTEM INPDESI
<br />DISCHARGE MONRORING REPORT FOMRI
<br />(1-I61 (17-191
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<br />MONITORING PERIOD
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<br />Form Approved.
<br />L T C° k F ' ~ ~ C ~ ~, /~ .,OMB No.f2040.0004
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTFY UNDER PENALTY OF
<br />AM FAMILIM WITH THE INFOR UW THAT I HAVE PERSONALLY E%AMIN
<br />MATION SUBMITTED HEREIN: MD BA ED MD
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<br />K l MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOfl
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<br />SIGNIRCMT PEMKTIE9 FOR SUBMITTING FAL$E INFORMATION
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<br />THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE IB U.B.C. 11001 MD 73
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRderence M/ efrschments here/
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