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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)
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEA_ MO D9Y_
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<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAMEITITLE PRINCIPAL EXECUTIVE OFFICER f certify under penalty of law that this document and all attachments were
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<br />OFFICER OR AUTHORIZED AGENT AREA
<br />TYPED OR PRINTED including the possibility of fine and imprisonment for knowing violations. CODE NUMBER YEAR MO DAY
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. ,~,p~ ~~ ~{.1TI'1`i~S~g..1?4-~~t'~~Tlll• PAGE OF
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