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<br />PERMITTEE NAME/ADDRE66 p~Y6 Frr57Nar//ovmm VD~.nwr1 rv,,i •,,, ~~~~
<br />NAME. _POLi1SBf10BM COAL CJMPAYX
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<br />ADDRESS 90AUS IDE NINE, K v 5 PORTALS
<br />P.U. BOX 1430
<br />PALISADE CU 41526
<br />FAaurv
<br />LocnnoN
<br />Af'fN: JU4h A. M~NABE P4ESIDENT
<br />DISCHMGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAV
<br />FROM TO
<br />lIO-III 11I-331 111-751 176-77I 128-19/ /30-311
<br />(SUBR iC)
<br />F - FIiAL
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<br />i4 To a ~~~0531-98 e
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<br />NOTE: Reed Inetruetlorr before cornpletln0 this loan
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<br />NAME/TITIE PRINCIPAL EXECUTIVE OFFICER I cERDFV UNDER PENN.Tr GF LAW THAT I NAVE PERSOSULr ExAMINED MD
<br />AM FAMILIM WITH THE INFORMATON SUBMITTED HEREIN; MD BASED ON TELEPHONE DATE
<br />II
<br />T ~ S T q ~ f t" MY INQUIRY OF TNOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNINO THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br /> TRUE, ACCUMTE MD COM0.ETE. I AM AWARE THAT TNERE ME
<br />SIGNIFICANT PENALTIES FOR 6UBMITTING FALSE INFORMATION
<br />INCLUDING -
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<br />THE POSSIBILITY OF NNE AND IMPRISONMENT. SEE 18 U.S.C. f 1001 MD 3]
<br />SIGNATURE OF PRINpPAL EXECUTNE /7[) ~/S y~U~ ~~eC C) 1 ~~
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<br />COMMENDS AND EXPLANATION OF ANY VIOLATIONS !Reference sl/ sttschmenrs hers) '
<br />:iEG PAST I.B.q POH UFTAILS OF TEST PROCEDURE. REPORT COYEST DILUTION (~ 1~FFLUEYT) NHICH IS LETHAL TO 50X'
<br />OF TEST U$GANLSRS {LC50) 9YD ATTACH ACUTE TULICITY TEST REPORT PO R!! TC D1+R• COFZES OF ALL INPORf7ATI0Y
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