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ERMETTEE NAMEIADDRESS pM,i FaWryNedLxmral UDlpoerU NATONAL POLLUTMT OISCHMOE ELMINATION SYSTEM INPOE'$1 FAQop~r~l~im Approved.
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<br />NAME/TITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF L
<br />AM FAMIl1M WITH THE INFO AW TNAT I HAVE PERSO
<br />RMATION SUBMITTED N NNIY EXAMINED MD
<br />MD BASW ON
<br />EREIN I TELEPHONE ~ DATE
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<br />MY INQUIRY Of TNOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FDR
<br /> OBTNNING THE INFORMATION, I BELIEVE THE SUBMITTED INFORMATION' IS
<br /> TRUE, AOLUMTE MD COMPLETE. 1 AM AWME TNAT TNEAE ME
<br />SIONIFICMT PENALTIES fOR SUBMITTING FN
<br />SE INFORMATION
<br />INCLUDING
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<br />THE POSSIBIUTr OF NNE MD IMPRISONMENT. SEE 18 U.S.C. S 1001 MD ]] 610NATURE OF PRI AL EXECUTIVE
<br /> U.S.C. f 1 ] t e. lhlrltl„ uNr INS mM„ m,Y txMl, rw, 1p N i IO,OW
<br />TYPED OR PRINTED wnnr.Tbn,n inprimmrn or Nlrwm 6manN, rN6ywA/ OFFICER ORA ORIZED AGENT CODE NUMBER YEAR MO D V
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS lReJerence a//s(lechmenfs Karel
<br />f55 b IFlON LI!fCf5 PILL B8 NA~rED AND SETTLEIBLE SOLIDS LIRIT ^PPLIED FOH C~iDlR,24HH Pi6CIp are>tTj TSS ~,
<br />IHUB L1pIT5 YAIiCU PO8 ~LDINe24tlN PRBCIP dYENT 308JCCT TO HBRD&N OP PHOOP Ilf 2.4:2. OIL $ R11E13E-SES
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<br />A orm 3 0.1 1 I rlvioui a Itmne may a ue (REPLACES FPA FORM T30 WHICH MAY NOT BE USm.) ~ PAGE OF
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