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PERMITTEE NAMEIAODRESS /lnrlutlr NATIONAL POLLUI AN i DISCHARGE LL IMINA I I V N S Y J I LM p.nlee/
<br />Irnli:y Nomr/lomtion UdUlrrrnU DISCHARGE MONITORING REPORT (OMR) OMB No. NH0-0OW
<br />YAME _,~ (,1 y~' ~(yf '~ ~ (j:; r~ 1. ~- - - - - - - /1-I6) !I7-I91 r - r' I V ,+ I' Approval exphee B-30~9I
<br />ADDRESS .iJ._1 fx11 r1 !~-_-_-_,_-_- ,~ 1 ' r';l L"~. I'.:III' rA(. (J !'A 1,. 1r r:."
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I CERTIF Y UNDER PENALTY OF LAW TNAT 1 HAVE PE
<br />T RSONALLY ExAMINED
<br />H TELEPHONE ~
<br />' DA T E
<br />AND AM FAMILIAR WITH THE INFORMA
<br />ION SUBMITTED
<br />EREIN; AND BASED
<br />ON MY INQUIRY OF THOBE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />~ //
<br />..
<br />
<br />, OBTAINING THE INFORMATION. I BELIEVE THE SUBMITTEO INFORMATION
<br />1'.. ti. A1'KINSUII ~ ~
<br />/"' /
<br />~
<br />~
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<br />IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIG
<br />~'Y LAND~HNVIRONI'IENTAL' AFFAII JNIFICANT PENALTIES FOR SUBMITTING FALBE INFORMATION, INCLUDING , .~
<br />/ , 3p3
<br />tS24-4451 92 UI ()0
<br />. THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 1B U.S.C. 1 1001 AND
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<br />d SIGNATURE OF PRINCIPAL EXECUTIVE '
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<br />TYPED OR PRINTED and or merimum lmpr4onmrnl oJMrwrnO monrN and fynn.) OFFICER OR AUTHORIZED AGENT NUMBER YEAR MO DAY
<br />COMMENT AND EXPLANATION OF ANY VIOLATIONS (ReJrnna all alrarhmrn/r hrrtl
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