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d <br /> DATE: m. <br /> TO: FROM: <br /> Central Valley Regional Water Quality - <br /> Control Board <br /> Attention; <br /> ORDER.NO-. RS-200.9-0097 <br /> CONDITIONAL WAIVER OF WASTE DISCHARGE REQUIREMENTS FOR <br /> SMALL FOOD PROCESSORS AND SMALL WINERIES <br /> WITHIN THE CENTRAL VALLEY REGION <br /> ANNUAL MONITORING REPORT FOR . <br /> (year) <br /> Discharger Name: <br /> Facility Name: <br /> Facility Address: <br /> County: <br /> I certify under penalty of law that I have personally examined and am familiar with the <br /> information submitted in this document and all attachments, and that based upon my <br /> .inquiry of those individuals immediately responsible for..obtaining the information, I believe <br /> that the information is true, accurate, and complete. I am aware that there are significant <br /> penalties for submitting false information, including the possibility of fine. <br /> (signature) (date) <br /> (printed name) <br /> I . <br />