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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM NPDES)
<br />DISCHARGE MONITORING REPORT (D R)
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAMEfTITLE PRINCIPAL EXECUTIVE OFFICER [certify antler penalty of law that this document and au attachments were
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<br />including the possibility of tine and imprisonment for knowing violations. OFFICER OR AUTHORIZED AGENT AREA
<br />NUMBER
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<br />EPA Form 3320-1 Rev. 3/99 Previous editions ma be used. _,~~ ~ :3 ~:~,t , PAGE .^OF
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