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<br />NAME SEFECA COA1 CCIIFINY rz-t6) m591
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<br />LOCATION YEAR MO DAY YEAR MO DAY
<br />tiwTDL31 CO 61630 )FROM -M>!•~-by-..~.- TO yy Uy .iU
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<br />C I N C h OMB No. 2040-0004-
<br />Approval expires 0531-98
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<br />NAMFJfITLE PRINCIPAL E%ECUTIVE OFFICER I CERTIFY UNDER PENALTY OF
<br />AM FAMILIAR WITH THE INFORM LAN"THAT I HAVE PERS
<br />ATION SUBMITTED HER ONALLY EXAMINEDTAND.
<br />AND BASED'ON)A1Y
<br />EIN / TELEPHONE DATE
<br /> INQUIRY OF THOSE INDIVIDUAL .
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINIHG~" r
<br /> THE INFORMATION, I BELIEV E THE SUBMITTED INFORMATION'IS TRUE; ~.
<br />ERErARE SIGNIFICANT
<br /> ACCURATE AND COMPLETE. I AM AWARE THAT TH
<br />: INCLUDING THE``
<br /> PENALTIES FOR SUBMITTING FALSE INFORMATION
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<br />OF FINE AND IMPRISONMEM SEE 78 U. S.C: 4 1001
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<br />~ SIGNATURE OF PRINCIPAL E%ECUTIVE (J
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<br />TYPED OR PRINTED , up to 570.000 era a.
<br />§ 1319. (PeWaies under these statutes may include Gnea
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<br />COMMENTS AND F~(PLANATION OF ANY VIOLAI IONS (riererence en erracnmenrs Here)
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<br />EPA Form 33261 (OB-95) Previous editions may not be used. (REPLACES EPA FORM T-4D WHICH MAY NOT BE USED.) C C 1 C' i / y y G E s 7 -1 L c ;, PAGE 1 OF
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