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fERMITTEE NAME/ADDRESS R.dIdIFcWryNrWLocenal /JD/Q a.) NATIONAL POLLVfMT DISCXMOE ELIMINATON SYSTEM IIYPDE$l
<br />NAME ~ ~ ~ .- . - .. ~ DISCHARGE MONITORING REPORT IOMRI
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<br />Form Approved.
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<br />NAME/i1TLE PRINCIPAL EXECUTNE OFFICER I CERT
<br />AM FA IFY UNDER PENALTY OF
<br />MILJM VATH THE INFO UW THAT I HAVE PERSONKIY E%AMINED MD
<br />RMATION SUBMITTED NERflN; MD BASED OM TELEPHONE DATE
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<br />~..•YI ~ Jy~,(r MY INQUIRY OF THOSE INDINDUALB IMMEDIATELY RESPONABLE FOR
<br />OBTAINING TXE INFORMATON, I BELIEVE THE SUBMITTED INFORMATION 19
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<br />EPA Farm 3320.1 108.881 Previous editions may bs used. IREPLACEB EPA FORM T-40 WHICH MAY NOT BE USED.1 0 ~ ~ T 3 ~ ,~ f 1 1 I T - 1 ~ ., . PAGE lOF
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