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<br />P.O. UGY 143J
<br />PALISADE CO 8153ti
<br />FACILITY
<br />LOCATION
<br />ATTN: ,IOhDi A. KCNAS, pRHSIDENT
<br />DI5CHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAV YEAR MO DAV
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<br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTI
<br />AM FA FY 1111DEA PENALTY OF
<br />MIUAII WITH THE INFO UW TNAT I HAVE PERSONALLY EXAMINED AND
<br />RMATION Sl1eMITTED HEREIN; AND BASED ON TELEPHONE DATE
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<br />=E Sy Q y' •' MY INQUIRY OF THOSE IMDINOUALS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />TRUE
<br />ACCUMTE AND COM0.ETE
<br />1 AM AWME THAT THERE ARE
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<br />SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING
<br />THE POSSIBIL17Y OF FNE AND IMPRISONMENT. SEE to U.S.C. ! 1001 AND 77 ~
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<br />EIONATURE OF PIIINCMAL E%ECUTR/E
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<br />TYPED OR PRINTED ens or nr+ilx+n MMmPe~+olMnrwnemmNargb y.ra/ OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANV VIOLATIONS (Re/erence a!/ slrochments here/
<br />SETTLEABLE SOLIDS IIHITS APPLIES ONLY IF <=1UYH~24HR PRECIPITAIIOY EVEYT IS CLAIRED. P.EAOZTTEE HAS
<br />UU4UL^ OF PRJOP NHEN RE;IUESTING aELIY:F PROM SETTLEABLE SOLIDS PPIt1ARY LIMITATIOlS.
<br />EPA Form 3320-1 108-96) Previous editions mey be used. (REPLACES EPA FORM Td0 WHICH MAV NOT BE USED.1 0 0417 / 9 A C 2 2 3 -12 5 E PAGE ~ OF
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