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T <br /> <br />F~M~ IN :CORDUIT OR wMPLE w K .h <br />2 <br />Zr~ r„ <br />D <br />S ~A#r.:ijoo <br />- a4t~+s0a <br />s 0+1V~!~,^- <br />! <br />;T 11£x2 PLAl3 t <br />•( U TP <br />E MEASUREMENTL SI1 <br />` <br />' . <br />J- . ~ - - I Q t / <br />~- ll'~ifh•i' <br />. <br />n <br />`_:ut:s0 1 '0 =;o _~' PeRMfi~.~ <br />a <br />7 <br />R <br />M T <br />t .?. ,pFfa~ t~ <br />':.is <br />"FtEF~O~`:r ~_ <br />~±,. <br />> <br />": <br />_ <br />&a+~a,g; <br />:1~. <br />a aanra~ <br />~.r r, <br />t .. <br />tl: <br />ap4 ar <br />A' ;:(9.. <br />I}S:o } ~' '.~exix HSTRN <br /> ~ <br />A <br />:DUI <br />E <br />. <br />` 1„ . <br />~ a.~:~;, tr <br />iP ./..~. r° ¢pff# <br />- :] " I <br />.;OLIDS, 1CTAL SAMPLE tr ~ya:ARL;} <br />a ~ Ipn(cfeY¢ <br />- <br />: '4AOa#fA: <br />' >)j.5p4 <br />^^dnI:7CX <br />': <br />~ <br />is MEASUREMENT ~i ..f. ~ :: .. r <br />~r r = ,_ _ .~ <br />7G295: I ff :.`.0 '.. ~ '.u'' Pb1Adr'..~ <br />' <br />. <br />q>~U " <br />,~ ',.~,ai71Aj1' aii^ <br />~ ;,ay I ~~t}a+o ~ ~a~'~~. <br />~ 'Pa~~aaac~- <br />tRicc -R~Pp~T,' : - .- 3 : ~A <br /> <br />;rp II P'r'T f.0 ^^ VAl.ai ;REDUIREMENT <br />, C?~rSr~ <br />' "/r .~ ':O+'~ <br />~~~:!~~ <br />t: t. e•; 3'~-0.'.`.' <br />r v< <br />t r <br />°X' ''C 7.',7•. <br />N] f <br />x <br />- nn <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER I CERTIFY UNDER PENALTY OF LAW THAT I HAVE P ERSONALLY EXAMINED : _ ~ ' ~ <br />- <br />' p TELEPHONE DAT E <br /> AND AM FAMILIAR WITH THE INFORMATION SVBMITTED HEREIN; AND BASED ~ <br />• <br />. ;, : 1l0y <br />r Lf`~3i3 Pi I fl~inf'C <br />~ ~ ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR _ Y :r _ , ~ i ~ -~ <br />~ ~ ~ ` , <br />~ <br />- ~. <br />•' <br />' <br />~ <br />, OBTAINING THE INFORMATION. 1 REDEYE THE SUBMITTED INFORMATION <br />19 TRUE <br />ALCUMTE AND COMPLETE 1 AM AWARE THAT THERE ARE SIG •r J <br />Y <br />' <br />- ~ ~ <br />4; C~ <br />1 <br />''~+~~ ' Cr• ~,L ' =~ -- <br />~ , <br />NIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING Cr~ <br />, <br />'" <br />.• <br />1y2 7IG-5253 <br />~ i <br />"/ ~ <br />~~• <br />~ <br />7 C'•' (` ~.~ F,' .. C'. ~~~~•~ '~^ THE POSSIBILITY OF FINE AND IMPRISONMENT. SEE 18 U.S.C. t 1001 AND , <br />SIGNATURE OF PRIN~IPAL ECUTIVE ~_~ ~ ~ I <br /> <br />TYPED OR PRINTED b US.C. 1 1310. nAlwhie .Mn rAa •rorvra nYF InNuh JLra uP ro 7!0.008 <br />sMo-rnmenrr+AnPrm'rrRrnr o/derwenemmnrNWl1'AYA/ <br />OFFICER OR AUTHORIZED AGENT <br />NUMBER <br />YEAR <br />Me <br />DAr <br />COMMENT AND E3fPLANATION OF ANT VIOLATIONS (R(fercnaeUel/arhmenY here/ <br />., I: <br />UIL AND DP,P.AS&. SEE FGUl'HGTE_.F/.::'O--RUST R°PORT IF F.XEHPTIONS CLALii.°.D. TSS MUST ~B3-R£FORT2D AT ALL <br />TIME5. -- ~ <br />A_ <br />~ Prw/ous ed/l/ons msy <br />USED) <br />6D035/LOOSl9-1744 <br />PAGE OF / <br />