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PERMITTEE NAME/ADDRESS (1eiW frSlryNa./Iacnm BDIpwsl)
<br />NAMI_ .p¢yDlrRNORN COIL COMPANY - - --
<br />ADORESSRDADSIDE MiNF, ti 6 S POR?ALS
<br />P.O. ROR lulu
<br />PALISADE CO 01520
<br />FACILITY
<br />LOCATION
<br />hT:N: JUNN A. l7CNAB, PHESIUCY?
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<br />MONITORING PERIOD eIYDA -
<br />YEAR MO DAV YEAR MO DAV~
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENN.TY OF LAW THAT I HAVE PERSONALLY EXAMINED MD
<br />AM FAMIUM WITH THE INFORMATION SUBMITTED HEREIN: µD BASED ON TELEPHONE DATE
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<br />C MV INOUIRV OF THOSE IHDINDUALS IMMEDIATELY RESPONSIBLE FOR
<br />OETNNINO THE INF011MATION, I BELIEVE THE SUBMITTED INFORMATION IS
<br />.-J TRUE, ACCUMTE MD COM0.ETE. 1 AM AWME THAT THERE ME
<br />SIONIRCIWT PENALDES FOR SUBMITTNO FN
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<br />COMMtNIS ANU tAYLRNRIIVN VF ANT VIVLAIIVNO IfreTefeeCl eN IRlC/ITIOIS DI/91
<br />:;EYYLEABL1e SOLIDS LINIT iPPLIES ONLY IF G=lUYN/24HA PRECIDITATICN EYEiT IS CLAIrED. PEANIT?EE NAS
<br />hURUEN UP PRDi7F i1NEN BEQUESTIYG kF.LIEF FROtI SE??LEABLE SOLIDS PfiIMAAY LItlITATI0i5.
<br />EPA Fam 3320.7 108-851 Previous editions mey be used. (REPLACES EPA FORM T40 WNICN MAY NOT BE USED.1 0 0 4 9 7 / 9 R C 2 2 3-1 25 E> PAGE 1 OF
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