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PERMITTEE NAME/ADDRESS (lirludeFxlTiryNmne/Locanon jD$..e„y
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<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
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<br />(20.211 (22.231 (24251 (2&2]7 (2&291 (30.31)
<br />Form Approved.
<br />,, ,,. ., OMB No. 2lW(1-0004
<br />1 _ i T I Approval eXpires OS-31-98
<br />ANOTE: Read Instructions bel re rp feting this loan.
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<br />NAME?ITLE PRINCIPAL IXECUTRIE OFFICER I CERTI
<br />AM FAM FY UNDER PENALTY OF
<br />ILIAR WRH THE INFORM LAW THAT I HAVE PERSO
<br />ATION SUBMITTED HERE NALLY EXAMINED AND
<br />IN; AND BASED ON MY TELEPHONE DATE
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<br />I~IChard h1f115
<br />INQUIRY OF THOSE INDIVIDUAL
<br />THE INFORMATION, I BELIEV
<br />S IMMEDIATELY RESPONSIBLE FOR OBTAINING
<br />E THE SUBMITTED INFORMATION IS TRUE, ~
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<br /> ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICAM C~
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<br />environmental h4anager PENALTIES FOR SUBMITTIN G FALSE INFORMATION. INCLUDING THE - 970-870-2712 7 28 99
<br /> POSSIBILffY OF FINE AND IMPR
<br />M ISONMEM. SEE 1e U.S.C. ¢ 1001 AND 33 U.S.C.
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<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference ell ettechments here)
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<br />EPA Form 3320.1 (08-95) Previous editions may not be used. (REPLACES EPA FORM T-00 WHICH MAY NOT BE USED.) PAGE
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