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TO "- S. <br />11tW0A ( UdN i(Cj;i'MN,TB~ , <br />n->'a~vu.TU-~ ~> ~~ncm nA-ool ,vaal NOTE: Read Instruetlons belore comDlethig thls form. <br />-~_~-'~~-'~~- --' ~ ~"-- ` -"' ,- <br /> <br />~ .. <br /> <br />PA~IAyETER' ~ <br /> <br /> <br />.. <br />~~ ~ ( Onb)"' ~-QUANTITY DR LOADING - ~ <br />~.~ J <br /> <br /> <br />/IbJJI =: /JIfi,) ~" ~ .. <br />~ (I Cq 09(YI- QUALITY OR CONCENTRATION I " -,' ~ - <br />'~ <br /> <br /> <br />(38aJ1 '-: 116131 /JI-6,) I - ~. - <br />NO. <br /> <br /> <br />EX <br />FREOUENGr <br /> <br /> <br />OF <br />SAMPLE <br /> <br /> <br />TYPE <br /> <br />i (37-~~~ :~ ~= <br />~ }'•: z~~~ <br />?~-A ERAG •T ;, <br />g ~ <br />'MAXIMUM. : <br />` - <br />I)NITS - <br />:; MINIMUId <br />AVERAGE <br />MAXIMUM ~ - <br />UNITS. <br /> <br />ldL63 ANALY$I$ <br /> <br />~ (6/-68) <br /> <br />(69-701 <br />. <br />,.. <br />- <br />~ F ~ <br />I - ' t <br />._...-.. <br />N-. r -: SAHPLB'. 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Q. i{ 7 <br />` ~ _ <br />.. i. <br />' 1 <br /> L u <br />r _ <br />- : <br />~ <br />L i - ~ <br />~~ <br />` f <br />~ ' <br />• - .. .r} r _r I- - • ~ L <br />y t <br />V <br />y' ~ <br />V <br />' 6~~dI~MIyH~( <br />~(P <br />I r~ <br />: <br />~ <br />~ <br />J T;~ <br />(J <br />I <br />~' <br />° <br />J _ <br />~ ~- <br />~ a ~ te s <br />` <br />~ <br />~ <br />~ <br />1 <br />' <br />~ _ <br />_ <br />_ ~ <br />~ ( ~ <br />~ <br />I <br />• <br />., <br />l: ~ <br />iLT R^'-^ _ . <br />~ <br />. <br />- rti. <br />,~L?s <br />ai 53 : ii„~ . <br />Y}~ :f. <br />%' <br />a i ~. <br />1 _.. .: [. if <br />1- S'P] <br />NAM E PHINCIPAC EYEPUTIVE OFFICER ? .1 LERiI <br />AND Al FT UNGEfl-PEHALTY OF LAW TNAT 1 NAVE P <br />t i~AMILIAR W1TR 7NE INFORMATION SUBMITT EPSONAELY'E <br />ED HEREIN <br />A XAMINED <br />ND BA$ED ~ v .- - ~ '' <br />~ <br />~ J+ ~ ~ <br />^ j TELEPHONE DAT E <br />- - <br />ON Mr ; <br />QUIRT OF tMOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR { <br />~ <br />I I <br />, <br />F - <br />' <br />Pa Du Rf e 3 ; N 7 <br />•, <br />'Brio(~ - <br />•-" r !-'~'"' ' y ~ OBTAIN <br />5 TRU „ <br />I D•TNE INFORMATION. I BELEVE THE SUBMITTED"INFORMATION <br />E, ACCUMTE~AND COMPLETE.1 AM AWARE TNAT THERE APE 610 , <br />' `, ~- <br />~ <br />~' '^ -~: i+ •- <br />C • <br />- ~ ~ ; :; <br />. <br />' <br />_ <br />Y ~ ~ <br />LK~1~P n z = I '~ ry , ~ NIFICA <br />7NE Po <br />-ii Ufl NT PENALTIES FOR $UBMnTING FALSE INFORMATION, INCLUDING <br />SSIBILRY' OF FINE AND IMPRLSONMENT=SEE fb U.9C.,E 1001'AHD, <br />0."~' 1]W <br />' IPt~r4b .Nn rAm ,mrurn Isa <br />llxfub p^ <br />IIO <br />DOO , <br />-. <br />~ <br />61GNA7UREOFPRINCIPAL CUTIVE _ <br />~f y <br />GOZ 'J/4-5253 y <br />'91: <br />01 <br />2° <br />_ <br />-~'PED Oq PRINTED ~ . <br />. <br />. <br />A <br />r <br />P <br />fo <br />aaewwulqutr NrPMmnnvnr o/hrwnlnronrbane lrrar,.l OFFICER OR AUTHORIZED GENT .NUMBER YEAR MO DAY <br /> <br />.. COMMERTANO EXPLANATION OF ANY NOLATIONS(RrJnenaaDOlMthmenu Arn/ <br />I~ t(~"'~I:+EH4HGE OCCgH~ dFPORT!(NO:.~pISCN.\lGt". <br />iJ.7t+ <br />'~I <br />OIG a-lo GR6A52~ SE8 PaUT!fOTE IF/. ~-=-~ <br /> <br />PAGE OF <br />400$4/900810-110: ~ <br />