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aERMITTEE NAME/ADDRESS (include FacilityNamoEocafion VDicrent)
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<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />PERMIT NUMBER DISCHARGE NUMBER - 11 -- I N ;?
<br />Form Approved.
<br />OMB No. 2040-0004
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I certify under penalty of law that this document and all attachments were
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<br />DATE
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<br />submitted is• to the best of my knowledge and belief, true, accurate. and complete SIGNATURE OF -PRINCIPAL C , , ty U { 03
<br /> I am aware that there arc significant penalties far.ubmitang false information, OFFICER OR AUTHORIZED AGE EA
<br />NUMBER
<br />YEAR
<br />MO
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<br />TYPED OR PRINTED including the possibility offreandimprisonment forknowing violations. ODE
<br />-OMMENTS AND E)(PLANATION OF ANY VIOLATIONS (Reference alf attachments here)
<br />PAGE
<br />OF
<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. form.
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