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PERMITTEE NAME/ADDREBS(lyYb FacWryNr/leea4w!/DI)J ra4) NATIONAL PoLLUTMT DISCNMOE ELIMINATON SYBTDA (NPDESI FOlm AppfOVed.
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<br />INS DISCHARGE MONITORING REPORT (OMRI
<br />12-151 77-1s1
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<br />No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF UW THAT I HAVE PERSONN.LY E%N.11NED MD
<br />AM FAMILIM WITH THE INFORMATION SUBMITTED HEREIN; AND BASED ON TELEPHONE DATE
<br />I , MY INQUIRY OF THOSE INDINDUALB IMMEDIATELY RESPONSIBLE FOR /
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<br />OBTNNINO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IB
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<br />1 AM AWME THAT THERE ME -
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<br />SIONIFICMT PENKTES FOR SUBMITTING FALSE INF011MATION
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<br />THE POSSIBILITY OF RME MD IM%NSONMFNT. BEE 1B U.S.C. 1 1001 MD 33
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<br />EPA Farm 3320-T 108-961 Previous editions may be uesd. (REPLACES EPA FORM T<0 WHICH MAY NOT BE USED.( PAGE OF
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