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PERMITTEE AME/ADDRESS pwdid. FsfGnNrW(ofgn~n lJbfBL{sr. _n E- +f ^'tr +IM(rTfONAL'1}O' DlSCHMdR[OLill~, ~'O s/;iEM'.%IN F,Sd f. 1 - ~: :, r ~t 'r ,f~ER APProved. - ~,. f <br />_...NAME- ~ r.l~ ~ 11 ~4,.r. A 1 ID ~. ,1.~yp~y~l.,a,>• '~,..~~, ~:. <br />.ADDRESS SII DL tl i M E , 11 6 $' '~it~i LS .,. .. , r - ^, j b $1-`I~1~j~h~L_ AP~[ogBfe~~°I ,'~ ~ , <br />p•O• BOx 1430 PERMITNUMSER OISCHMOENL•AeER F - PIMAL <br />~., ~. <br />fF AILLJ•LV /• - W OlJ i0 - - - ,- •. 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ES=-r--- .. <br />, <br />, <br /> FFLUSMl.~}ROSS 9AL0 ,REnu1REMEf~T: ,~;~~1=; Y0=0 •300 <br />Y <br />, <br /> NAME/TITIE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF <br />AI <br />M WITH THE INFO LAW TNAT I HAVE PERSONALLY E%AMI <br />MD B <br />RMATION SUBMITTED HEREIN NED MD <br />ASED ON TELEPNONE~ DATE ' l <br />~ <br />i <br /> ~ 1~ <br />~"T ( <br />1•~ Cr <br />T ~ AM FM <br />LI <br />MY INQUIRY OF TNOSE IN <br />OBTNNING THE INFORMATION ; <br />DIVIDUALS IMMEDIATELY RESPONABLE fOR <br />THE SUBMITTED INFORMATION IS <br />, I BELIEVE ~ I~ <br /> , <br />, TRUE, ACCUMTE MD COM <br />T <br />F <br />R . <br />RETE. .I AM AWME TNAT THERE ME <br />KSE INFORMATION <br />INCLUDING <br />BMITTING <br />S <br />~ ll~~ <br />`1 <br />~1 <br />/ <br />'1 <br />q <br />( <br /> A C <br />P <br />~ SIGNIFICMT PENAL <br />IES <br />O <br />THE POSSIBILITY OF FNE MD , <br />f <br />U <br />IMPRISONMENT. SEE 16 U.S.C. 1 1001 MD 3] SIGNATURE OF PIIINCIPAL E7EECUTR/E y <br />0 <br />I / i <br />~- <br />~BI <br />~i 7 7 f D <br />.L O~ O r I <br /> I <br />~ <br />- U.S.C. f 131e. fPrWll•• rner 1M•r mvfo r.Y McAW. lxws y ro J 10.000 <br />T <br />E <br />T AREA <br />NUMBER ~ <br />YEAR <br />MO <br />DAY <br />' Y <br />1 <br /> J <br />TYPED OR PRINTED rK rnwMUe Mwf>•ml.+l o/MM•rlsnlmNa•M6/oral OFFlCER OR AU <br />HORIZ <br />D AGEN CODE ' , y <br />_ <br /> <br />COMMtN I S~ANU C><YLANF I lun ur ralrr Yw~n I wlr~ Innrrrncr an suecunon.r nvq - <br />]t :'l B <br />THIS Otl3P~bi. ~S 1104 BLIGIBL$ POR fiXB!(PTIOBS PROtl TOT SL 5(75 PEAC6D 50LIC5 (TSS) F 70TA'L IRON AMD/OR ~,~ <br />SETTLSABLB :SQLIDS LIMI3ATI0lIS - SEB I.1.2. `^~ <br />f. <br />EPA Fwm 3320.1 10&-85) Previous editions mey be used. (REPLACES EPA FORM T•40 WHICH MAY NOT BE USED.) as 3 2 2 /98 C 22 3-125 6 ~ PACE Iop - <br />