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<br />NAMERRLE PRINCIPAL FXECUTNE OFFICER I CEIITI
<br />AM FA FY UNDER PENALTY OF UW THAT I HAVE PETISONALLY FXAMI
<br />MIUM WITH THE INFORMATON SUBMITTED HEREIN; AND BA NED MD
<br />SED ON
<br />~ TELEPHONE DATE
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<br />Cd/Utrl/!1 JE~r /-~
<br />MY INOLYRY OF THOSE INDIVIOUAlS IMMEDIATELY RESPONSIB
<br />OBTNNING 7HE INFOMIATION, I BELEVE THE SUBMITTED INFORMA
<br />LE FOR
<br />TION IS ~ ~ ~
<br /> TRUE. ACClB1ATE MD COM0.FTE. 1 AM AWME THAT THE
<br />SIONIRCMT PENAL11E5 fOq SUBMITTkIG FALSE INFORMATION
<br />IN RE ME
<br />CLUDING 1
<br />I n
<br />A/. ~ IJ/" /7r1 r / S ,
<br />THE POSABILITY OF qNE MD IMPIBSONMENT. SEE 18 U.S.C.1 1001 MD 39
<br />BIONA7URE OF MINCWAL EXECIFTNE q ~
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<br />TYPED OR PRMVTED r.swan.r..wl.Mwl....,.+rwer»w+e,.w.m•.vsr...l OFFlCER OR AUiHORgED AOEiR C~ HUM9ER YEAR MO DAY I
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS IRelerence ell ettechmsnts here/
<br />,F;TfLEABLE SOLIDS LICIT APPLIES ONLY IF <=l0YP,24HR PrifCIP EVF.9T IS CLALf1ED. IF: CLAIM APPROVED r•Y a,~CD,
<br />255 E IRON LZtIITS WILL NUT f3E APPLI°D TO REPORTED n.°.ASUR~'MENTS-SP.F. T.A.2, PG 4, FJR A!):?DEk DF PRDOF
<br />EpA'F 1 P1 - ^ etlitio a u atl: • • • Ift Y T B • ~~ • • + • PAGE OF
<br />4U212/971'606-15u1 ~
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