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<br />NATIONK POLLUTMT DISCHMOE ELIMINATION SYSTEM INPOES) Form Approved.
<br />DISCHARGE MONTTORINO REPORT IOMRI ., TOMB No.-.2040-0004 ,
<br />11-161 17-191 '- "
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTFY UNDER PENALTY OF L AW THAT I HAVE PERSONALLY E%AMINED MD TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFO RMATION SUBMITTED HEREIN; MD BASED ON
<br /> MV INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />i:lchard ^1I!I'I OBTNNING THE INFORMATON, I BELIEVE THE SUBMITTED INFORMATION IS
<br /> TRUE, ACCUMTE MD COMRETE. I AM AWME THAT THERE ME
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<br />SIGNATURE OF PpINGPAL EXECl/TIVE ~(,
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<br />TYPED OR PRINTED u.s.c. E IJIa. ltNwe.. uw. err mnm• nr.r beANN rxwa w ro 710,000
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<br />OFFICER OR AUTHORIZED AGENT gREA
<br />CODE
<br />NUMBER
<br />YEAR
<br />MO
<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lRerorencs s// sftscnmenfs here/ -
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<br />EPA Form 3320.1 108-951 Pravlaue editlona mey be used. _ IREPLACE6 EPA FORM T-40 WHICH MAY NOT BE USED.1 r _ . t r ., . ^ _ _ PAGE , OF
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