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1 <br />1 <br />1 <br />1 <br />1 <br />1 <br />1 <br />1 <br />t <br />1 <br />1 <br />1 <br />1 <br />"l certify under penalty of law that this document and all attachments were prepared under my direction or <br />supen~ision in accordance with a system designed to assure that qualified personnel properly gathered and <br />evaluated the infotmatton submitted. Based on my inquiry of the person or persons who manage the system. <br />or those persons directly responsible for gathenng [he information, [he information submitted is to the best <br />of my Imowledge and belief. [rue, accurate, and complete. f am aware that there are significant penalties for <br />submitting false information, including [he possibility of fine and imprisonment for Imowmg violations." <br />of Owner <br />(printed) <br />_~ . <br />l ` ~-~~ L <br />Signature of Operator <br />Y~N ,KUr <br />Name (printed) <br />+..,.s. ~.rv sya.a <br />~_ <br />.'v ~rnl <br />Date <br />ate Signed <br />Page <br />ICI <br />