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<br />~ERMITTEE NAME/ADDRESS Onclude Facility' Nome4ocanon JDifferenU
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<br />OMB No. 2040-0004
<br />!! I N O R Approval expires OS-3t-98 .
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<br />NAMElTITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EJ(AMINED AND
<br />AM FAMIUAq WRH THE INFORMATION SUBMITTED HEREIN
<br />AND BASED ON MV TELEPHONE DATE
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<br />INQUIRY OF THOSE INONIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING ~
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<br />GDMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell attachments here)
<br />GOeiZTOYZNG RE:UIti£CF:?iT5 S£? I.'.l.r+, Pr, '~, PlIFDIiN OF PROOF >9EQUTAB.!(¢~?S - SFE I..4.3, PG. 4.
<br />EPA Form 3320-1 (08-95) Previous editions may not he used. (REPLACES EPA FORM T-40
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