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MX.. <br /> <br />MGU ~ ~ ~ . <br />~ ~ ~ ~'~~ <br />„~: ,..::.:: <br /> <br />;.: <br /> <br />t•~,~tiy <br /> <br /> <br />. . <br />•L SAMPLE <br />. _ MEASUREMENT <br /> PERMIT'...::. ,:.:. <br />:.. :...:. <br />':E:- i <br />' IiEQUIF <br />EM~N7 <br />' : <br />..:::::~ ::~~~~~ <br /> : <br />. <br />i <br />. <br />~. ~... ~ :.. :...::. .: :,. <br />..: ~' ..:.:..::x.. ~. .....: ,.. ~.' ~.. <br />~ <br />NAMElTITLE PRINCIPAL EXECUTNE OFFICER I CERTIFY UNDER PENALTY OF Lww THAT I <br />HAVE PERSONALLY EAAMINEO MD <br />AM fAMIUM N4TH THE INFORMATION SUBMIRED HEREIN <br />MD GAGED ON <br />- TELEPHONE DATE <br /> ; <br />MY INQUIRY Of THOSE 'IN[IIVIDUALS IMMEDIATELY RESPONSIBLE FOR <br /> <br />I' <br />Irlli'rd !' <br />91115 OBTNNINO THE INFORMATION, I BELIEVE THE GUBMIREO INFORMATION IS <br />TRUE, ACCUMTp MD COMPLETE. I AM AWARE THAT THERE ME ~ j <br />~ ~ <br />L ' <br />, <br />. SIONIFCANi PENALi1EG FOq GUBMIRINO fALGE INFORMATION <br />INCLUDING A <br />r_nviror,rnental ti+IaEILtU C , <br />TNEPOS5IBNTYOFRNEMDIMPNGONMENT.9EEtBUS.C.It001M0G] BIONATUREOFPRINCIPALEXEgJTIVE 17 7 - 71 /1 ~~ 971 <br /> <br />TYPED OR PRINTED U.s.C. 1 t G16. I/WrIeM up.r Nr~ mum.. .Iar iKA.dI AMF w ro t IO,00p <br />NOwmulmvn irWlor,wtr e/bfwwn 6navM. rW6yw..l <br />OFFICER OR AUTNORRED AGENT <br />CODE <br />NUMBER <br />YEAR <br />MO <br />DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Ra/erenca s// stfschmenrs hare/ <br />~LL:p L1MlT AI'F'Llt~ TI, GLi:MnirvEU FLUrI FRW9 Ji;jF OLD v ,i~4• .)lL -. u,~tAst v+LA!1 SAHPL~ ANALT~IS ataJllt _~_ :I <br />ri~1CLL ShEtrv 1~ t,:,St~tr`tL'. rkTKLY Sar.r~LI~G 1NSIkU(.fI'~i;i-I.L._„ Ni, X. <br />EPA Form 3320-1 10&-961 Previous editions mey be used. (REPLACES EPA FORM Td0 WNICN MAY NOT BE USED.) UUU 1 ~3 ~ 961 J 01' 13.1 I PAGE iOF <br />