Name of alleged offender/ Enw'r tramgwyddwr honedig:
Address/ Cyfeiriad:
I, /Mae gennyf fi ___________________________ (1)
an authorised person acting on behalf of the Natural Resources Body for Wales, / sy'n berson awdurdodedig sy'n gweithredu ar ran Asiantaeth yr Amgylchedd,
have reason to believe that on or between/ le i gredu eich bod ar neu rhwng _______________________ (2),
...
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