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<br />NATIONAL POLLUTANT DISCHARGE EUMINATON SYSTEM MPDES)
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<br />PERMIT NUMBER DISCHARGE NUMBER
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<br />Form Approved.
<br />,~ T,T .. OMB No. 2040-0000
<br />1 Approval expires 05-31-95
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTFY UNDER PENALTY OF
<br />M FAMILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMNTED HERE NALLY EXAMINED AND
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<br />~achard Lillls A
<br />INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPON
<br />1 BELIEVE THE SUBMITTED IN
<br />THE INFORMATION ;
<br />SIBLE FOR OBTAINING
<br />FORMATION IS TRUE ,
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<br />I AM AWARE THAT TH
<br />ACCURATE AND COMPLETE ,
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<br />~ ~~~~" 97O-B7O-27]2 5 24 99
<br />[nvlronlnental tiwnager PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE
<br /> POSSIBILITY OF FINE AND IMPRISONMENT. SEE to U.S.C. 41001 AND 39 U.S.C. SIGNATURE OF PRINCIPAL EXECUTIVE
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<br />TYPED OR PRINTED § tat e. (PeneNes antler Mete stsnrtes may Inc/uoe lures up m 510,000 en0 a
<br />msximum lmpnsonmorx of oetwsenamonHU enoSreers.) OFFICER OR AUTHORIZED AGENT
<br />NUMBER
<br />YEAR
<br />MO
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
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<br />EPA Form 33267 (OB-95) ^Previous editions may not be used. (REPLACES EPA FORM 7d0 WHICH MAY NOT BE USED.) ,t ,,, T T /,1 ~ ~ ,I 1 ~_) r ~ rr PAGE 1 OF
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