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PERMTTEE NAME/ADDRESS (IIIfIYdL' NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NFDE$)
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<br />- c T .; b OMB No. 2040-0004
<br />•• f ', ', ^ Approval expires 10.31-94 •'
<br />NOTE: Read instructions before completing this form.
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER i CERTIFY UNDER PENALTY OF LAw rHAT I HAVE PERSONALLY Ex AMINED TELEPHONE D A T E
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<br />5, M ~ OlJ~1.LY ON MY INOUIRV OF TIgSE INDIVIDUALS IMMEDIATELY RES~NSIBLE FOR
<br />OBTAINING THE INFORMATION. i BELIEVE THE SUBMITTED INFORMPTION i5
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<br /> TRUE ACCURPTE AND COMPLETE I AM AWARE THAT THERE AFE T
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<br /> SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATON INCLUpNG y
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<br />orm 3320-t (Rev. 9-88) Previous editions may be used (REPLACES EPA FORM T.40 WHICH MAY NOT BE USED.1
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