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:RMITTEE NAME/ADDRESS(1nr1'JrFmMlnyNw/loe,rio, UDr~riu0
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<br />Form Approved.
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<br />A'pProve sx.i 905-'31x98
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<br />NAMElTITLE PRINCIPAL E)(ECUTNE OFFICER 1 DERTI
<br />AM FA FY UNDER PENALTY OF LAW'TMATI HAVE PERSONALLY E%AMIN
<br />MIIIM W1T/1 THE INFORMATION SUBMIttEO HEREIN
<br />MD BA ED AND
<br />SED ON ~ . TELEPHONE DATE
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<br />Rici~aYd h11lls :
<br />MY INDUIIrY OF THOSE IM INOUKS IMMEDIATELY RESPONSIBLE FOR
<br />OBTNNINO iNE WFORMA71 I REDEYE THE SUBMITTED INFDMIATIDN IS ~
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<br />E~TVironmental M;alTager TRUE, ACCUMTE MD COMPI.EfE. 1 AM AWME TNAT TNERE ME
<br />SIONIFICMT PENAlTlE9 FOR SUBMITTING FALSE INFOMIATION, INCLUDING
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<br />(970)E70-2712 1,
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<br /> THE POSSIBILITY OF RNE AND IMPRISONMENT. SEE IB U.S.C. F 1001 AND ]3 BIONATi1RE OF
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<br />EPA Form 3320-1 (08.96) Previous editions may bs used. (REPLACES EPA FORM T~40 WHICH MAY NOT BE U9ED.1 U (i i `~ y/ it I U ~ I - 1 ~ 11 PAGE lOf
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