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REnu1REMENT ~~$A.':-YG . , . liAILY il.X' MGD ~_ #### NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1f111J°"rrprll•IJ° •.In'11"1'°°1""`nI.M .Il .lnr""""°"`^ pnp.IM uldr. mJ all.°a°n °r wpenH°" m.a°ra.w..lm .,Jar,,, ay[nra TELEPHONE DATE ` ``K~ -~ + ,~1G 1° awurt IM1.1 qualllea pennnnd pr°prtlJ plnrr nM v.lmle In° Infonmll°n wEM11ed lW nn mJ lnqulry of NtMl.onwprwu .M1O nun. r lne , rlrm ---- ~-v l ~~ [ J , o IM1 tll /I MEk f l1 r rrc O,r pemm J 1npo n [nlM1erln[ IM1e Infnrnutlen, IM1e Inform.llen ' ~a 1 I~ NQ r ~C vw:cc„w~,= C wnmluea h, 1° IM1r Ent of ~nJ M1n..ka[e.na NIlrf.lrve..ttvr.Ir..1M mmplrlr. 1.,n...,.u.1 iTr.r.na[nmom p.n.mn f°rwEnlluln r.minf°nn.no 61°NA7VRE OF MIIHCRAL EXECUTIVE 3u3 1 1 ~;u -4u 1„~ ~ ` ~ ~, \ ~ [ n. I w TYPED OR PRINTED na alna lE•peJ.ElxrJMnM.na ln,rl,onmenl rnr M1n°"In[.l°I.uo1n OFFICER OR AUTHORIZED AGENT CODE NUMBER YEAR MO DAY COMMENTS AND EXPLANA7IVN of• nnr vIVLA I IVNS (R~!/IInC~ e4 ~EbCDTInh Aay ~TTL_ABLE SOLIDS LIgIT BILL BE 4AIYED FOR >l0YR,24HR PRZCIP EVENT-SEEI.A.S, PG. 9, FOR REQUIREMENTS. ,.nTftLY SAHPLING INSTRUCTI0115-I.C.lU, PG. 12. Fwm a32o-t {)~ 3/99) Previous „ ~ ''/'~. may be used. 00190/0 i usJiu ~ 4-p~n4form. .~ - M 3:.i 4~, ,11L. i~:~