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PERMITTEE NAME. SS lrmY4 sxrOryNr/IxM+m 1/Dyb..O
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<br />ADDRESS (; p 1.11 . ') ;! I \ ~.
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<br />NATIONAL POLLUTA CHMOE OJMINATION 9Y9'TEM /NPOESI
<br />OISCMAR ITORING REPORT OMRI
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<br />PERMIT NUMSER DISCHMOE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM 9tl lU U1 TO 9P ?? :il
<br />!16111 lZ2-191 !7I-I5) 1/6171 118-191 !36311
<br />Form P vad. •~
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I cERTIFr urroDl PENUr GF
<br />AM FAMILIAfl WITH THE INFO uw THAT I HAVE PERSOrrul.r ExAMINED AND
<br />RMATION SUBMITTED HERON: AND eASFD OM ' , TELEPHONE DATE
<br /> MY INQUIRY OF THOSE INDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> OBTNNINO THE INFORMATION, 1 BELIEVE THE SUBMITTED INFORMATION I9 'I
<br /> TRUE, ACCURATE AND COMRETE. I AM AWARE THAT THERE ARE\,
<br />TIES FOR SUBMITTING FALSE INFORMATION
<br />INLLUDING
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<br />TYPED OR PRINTED WarmuYnun hw/e++wn of bnrw,emonMA rMSyAral ~ OfFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EAPLANATION OP ANY VIOLA 71VN5 (Hererence sll ettecnmsnrs oars!
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