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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM INPOESI Form AppIOV _
<br />DISCHARGE MONRORINO REPORT D~ OMB, No; 20
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<br />NAME/TffLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY unom PENALTY of
<br />MILIAR WITH THE INFO uw THAT I HAVE PERSONALLY ExAMINEO AND
<br />RMATION SUBMITTED HEREIN: AND BASED ON TELEPHONE DATE
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<br />~ MY INDUIIIY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
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<br />' OBTAINING THE INFORMATON, I BFLIFVE THE SUBMITTED INFORMATION IS
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<br />j TRUE, ACCURATE AND COMRETE. I AM AWARE THAT THERE AAE
<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />THE POSSIBILITY OF flNE AND IMPRISONMENT. SEE 18 U.S.C. ! 1001 AND 93 giONATURE OF PRINCIPAL EXECUTNE / ~' ~ ~ I r
<br /> U.S.C. f 13th. (iMWeLr MrWr Maur Wroroa nrY YKA,d~ /ins 4> ro i 10,000 AREA
<br />TYPED OR PRINTED nawmuinr.n.HrplaawnnrMbMrn4manMa ~nd6 ywal OFFlCER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAV
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<br />EPA Form 3320-7 108-951 Previous editions may be used. (REPLACES EPA FORM T40 WHICH MAV NOT BE USED.1 PAGE OF
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