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<br />DISCHARGE MONITORING REPORT (OMR)
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<br />PERMIT NUMBER DISCNMGE NUMBER
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<br />YEAR MO DAY YEAR MO DAY
<br />FROM `7 ' ~ 'I TO ` '
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<br />Form Approved.
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<br />NAME/TRLE PRINCIPAL EXECUTRlE OFFICER I CERTIFY UNDER PENN.TY OF LAW TNAT I NAVE PERSONALLY EXAMINED MD TELEPHONE DATE
<br /> AM FAMILIM WITH THE INFORMATION SUBMITTED HEREIN; MD SASED ON
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<br />SIGNIFICMT PENALTIES FOfl SUBMITTING FAISE INFORMATION
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<br />EPA Form 3320.1 108-951 Previous editions may be used. (REPLACES EPA FORM T40 WHICH MAY NOT BE USED.) n 0 ~ 4 ~ / ~ n r 1 ~.7 _ L ~ ? ,I PAGE r OF
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