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PERMITTEE NAMEIADOREBB O..r4 F.rWry NrWLrrlm IJD1Jjr.nU NATIONAL POLLUTANT DISLHMOE ELIMINAnON SYSTEM (NPDESI Form Approved.
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<br />NAMERITLE PRINCIPALEXECUTIVE OFFICER 1 tERnFr uNOER PENALTr oFl(+W:rNAY tt+AVE PERSONAIIr ExuAINED MD ~ TELEPHONE DATE
<br />AM FAMILIM N1TN TTryryE INFOflF1ATION SUBMITTED HEREIN; MD BASED ON
<br />MY INQUIRY OF TN09E INDI~IOUAl9 IMMEDIATELY RESPONSIBLE FOR //~'~/
<br />OBTAINING THE INFONMATION,,1 BELIEVE THE SUBMITTED INFORMATION IS / / ' /' i
<br />P.ir_hard Mills TRUE. ACCURATE MO COMPLETE.' ! AM AWME TIAT THERE ME 1
<br />IIA SIONIFILMT PENALTIES FOR SUeB~ITTINO FALSE INFORMATION, INCLl1DIN0
<br />Environmental area er THE POSSIBILITY OF FlNE MDIMPIIISONMENT. SEE IB U.S.C.11001 MD9S v 970 B7O-2712 1 Z8 n~
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<br />TYPED IM PRINTED .nsn-,n..N,un MmY.gPl,r,rwbn...nemrldu ride Yra/ OFFlCER OR AUTHORIZED AGENT CppE NUMBER YEAR MO DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS fRderence ell attachments hare/ ~ i
<br />rLLw LinlT AYpLttS Tu L;1r1O1NcL rLUN FRLrM OUj, 01[ G ..tea. uIL 8 GREASE GkAu SAMt~LE ANALYSIS kE;yUlrtti. iF
<br />Vl~ll,lc ~HLEIY 1~ (1d SLk VtI,. GkTkLY SAMPLIIV i, IfiSTkUCT IUN;i-I.G.tiE PG X.
<br />EPA Form 3320-T (08.951 Previous editions may 6e used, (REPIACF.S EPA FORM T•40 WHICH MAY NOT BE USED.1 UU u 2 y / Yo 1 uu 1-1311 PAGE OF
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