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<br />NAME ~ DISCHARGE MONRORINO REPOi1T (OMR)
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<br />Form Approved.
<br />OMB No. 040-0004 -
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<br />NAMERITLE PRINCIPAL E%ECUTNE OFFICER I CERTI FY UNDER PENALTY OF LAW THAT I HAVE PERSONµLY E1fAMINED MD TELEPHONE DATE
<br /> AM FA MILIM MATH THE INFORMATION SUBMITTED HERON: MD BASED ON
<br /> MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR
<br /> OBTNNING THE INFORMATION, 1 REDEYE THE SUBMITTED INFORMATION IS
<br /> TRUE, ACCVMTE AND COMRETE. I AM AWME THAT TXERE ME <~~ ~/
<br />
<br />SIGNIFICMT PENALTIES FOP SUBMITTNG FALSE INFORMATION
<br />INClWINO F
<br />' ~
<br /> ,
<br />THE POSSIBILITY OF FNE MD IMPI1150NMENT. SEE 18 U.S.C. ! 1001 AND J3 • ~
<br />ONATURE OF PRINCIP
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<br />TYPED OR PRINTED aneamvrnun MAd+emNnt arbnrwn ammaha And6 r..rcl OFFICER OR AIJTHORI2ED AGENT CODE NIIMBE~1 YEAR MO DAY
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<br />EPA Form 3320.1 108-961 Previous editions may be used. (REPLACES EPA FORM T-40 WHICH MAY NOT BE USED.) PAGE OF
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