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V „ <br />'r+ <br />:' _ <br />ne <br />9w , <br />~mys„ <br />"e <br />f ~ „ <br />. <br />. <br />r <br />~'" i~0 •sT' <br />s O <br />4 <br />~i'/ro Vqe <br />s A'a -~ w `S ..y <br />. <br />^s <br />c <br />, d RI ~b <br />' 5 <br />6'xy { &' <br />. <br />~ <br />u-3n i g:Yi <br />kr <br />~ <br />.. '. frxw . <br />a <br />- . <br />ne <br />y « <br />~ <br />J~k <br />are ~>8^ ~ <br />IIc ~br.. ~ <br />) <br />sic <br />..: me. <br />. d" a <br />NAMlRITL[ PRINCIPAL [%[CUTIV! OFFICER 'I C[RrIFr UNDER <br />w[NALTr <br />OF LAw <br />THAT I HAVE F[RSONALIr [IAYIN[D - _ - <br />AHD AY FAMILIAR wITH TH[ MF011MATON SUBMITTCD N[REM AND MSCD ~ ~ ~~' -: <br />` TILRNON! D A i E <br />1/~ ~ C- ~- <br />(A/f N~ ... .,^ ` ~- _ <br />~.~~ ON YY INDUIRY Oi TMOSE INdVIp1AL5 IMMfpATELr RCSPONSIBLE fOR. ~~_ <br />OBi AININL THE INFORMATIO.'r. I BEi1EVE THE $UBMITT[O INFORMATION <br />~ ~. - ~. <br />;. ~: <br />, <br /> <br /> <br />~ <br />': <br />' <br />lf~ <br />IS TRUE. ACCUPATE AHD COMPLETE I AM NWAR! THAT iHCR[ AR[ 51G <br />NIFICANT PENALTES FOR SubdITTML FALSE INFg1YAig11. INCLUpHL ` <br /> <br /> <br />G <br /> <br /> <br />~ <br />rl <br />SI, ervlsCr <br />.~n~• r <br />~ THE PO551&LHY.OF FINE AND MPRrSpHMCNT SC[ IB u5C 11001 AND 61gNATU E OF PRINCIPAL E%ECVTIVE <br />D u5C f 1019 rP <br />M•r rnrr uarvrr. n <br />In l14IXwr <br />~sr <br />lr <br />ld <br />/ <br />n c'Z 97Y 51 ~ f <br />- <br /> <br />.L TYPED OR PRINTED r <br />rm <br />RS u <br />nr <br />r <br />m <br />VO <br />a.d ~.rrn.r~mun rn~Pn.,nrn~.rU ~~/A.~ruwnAmunrA. and .{.r.F.r OFFICER OR AUTHORIZED AGENT <br />NUMaER <br />YlAR <br />MO <br />OA <br />GOM MENT,ANO EXPLANATION OF ANT VIOLATIONO (Rrlornn all mmanmrnu nrrrl <br />SEE PAP.T -I.F3~DF PERMIT FOR CF.'IAIl.S OF TEST PI20CSDUHF. R5F'ORT 4E'SULTS OF IBC TEST .4S YnIN[ryIIMN AND 5!)'; <br />lIORTALIT7 TEST (ANY CC'NCF.NTNATION) q:, ">14%IKllit'r AIID AT?Arn A('pTF TnCICITI'TCST R°FnRT FC4'+ T7 DEF. <br />E i°or 20-1 (R 8)' ~ /. ua Ad Dha a bB u5 ' . IRaF LACaa eFli ~o 'T- 0 w kn MAY Nor •a usE D.I Fwca of <br />DJi'';4/o~gF,l'i-1.:41 1 <br />