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<br />NATIONAL POLLIR'ANi DISCHARGE ELIMINATION SYSTEM MRDES) Form App/OVBd.
<br />DISCHARGE MONITORING REPORT (OMR) OMB N0. 2030-0004
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<br />NAME?ITLE PRINCIPAL EXECUTIVE OFFICER Icenay antler penelry Mlaw mat mis dout,menl antl en anacnments were TELEPHONE DATE
<br /> pYepareO under my tlirection or eupenision In accordance wMh a system designed
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<br />' to assurv Nat Rualrfed personnel properly gather and evaluate me Inbnnation
<br />Based onnryinqulryofinepereonorpersonsvanmanegemeeyelem
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<br />President/General Mana er submMed ls,to me best of my knowletlge end ballet, true,eaurete, end conplete. SIGNATURE OF PRINCIPAL EXECUTIVE
<br />~.'ryPED OR PRINTED lam aware met mere are slgniAtara Penalties br submitting false lnbrmation,
<br />InciudinP the DOSSibilay Merne end lmprisonmem br knowino NOlatloru. OFFICER OR AUTHORIZED AGENT
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference al/attachments here)
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