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eaa N+ITWI :: <br />F~rldr N~rne/Lomlion' •enl/ ~~ ". <br />NAME=~~~~~ !!~ ?[Ir},~ <br />ADDRESS ~,~~.~~__;_ <br />__ __ cr . <br />FACILITY _~--_------' <br />LOCATION__-_-__ --'._-- --~ <br />n TTf;] nF rote=crcU CVCnr ovv, <br />NATION <br />{F+AZ--- ~~ ~. I 1 <br />I ~ , .. ....... <br />f lT~ - <br />- :FROM <br />~~ I <br />ELIMINATION SYSTEM (NPDESJ <br />MG REPORT.(Dhfg/: II <br />;I, I I I-1 II ri <br />'~ <br /> <br />'' ~) I I T'' Sl'OkMli~TER, ~ ."iB(~IL SPA t1I;iL• <br />> I'~, I DISCHARGE NUMBER ~ . li ~x'-^' - ' <br /> - <br />IN 'PER'IOD ~ - it <br />I ~•I ~i I" <br /> ~ <br />~ <br />I ~ ' . <br />~ <br />1: ;YEAR MO DAY . <br />• <br />II <br />.. <br />- <br />`l <br />To ~ <br />"' :/z~cm Dxa91 /3aiu.. ri a .. ~It'rrs <br />nir+oa': I~ <br />NOTE: Reai1 In~tructdolis bolore completing this loan. <br /> ' ~. (3 CPni Onlyl ~. QUANTITY OR'LOADING; ~''j ; <br />I ' <br />' I1 Card Only)- QUALITY OR CONCENTRATION i ~ " <br />' <br />' NO. 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'` <br />~ <br />` <br />¢ t ~ <br />} '~ ,r.^t <br />.}'~ ~ ~ <br />' '• <br />~.~-'r ' L~' ~I~ <br />. <br />J: G <br />i <br />`J i, a I <br />• <br />: <br />II' ; .I !: iw, ;_ <br />_ <br />. .. <br />:] : ,REOUIREY <br />_ ,.YA s <br />P .•["i ~•.~"1: <br />,TJ' T'i.'1 .m<]: -- V v . n.: ~ <br />'~,..., ~ ~'" ~ <br />. , <br />. <br />," r <br />iY •: ~~: II r7 : <br />. <br />.1 <br />.If r , .'!% <br />11 <br />_ . <br /> <br />.; <br />NAMERITLE PRINCIPAL EXECUTIVE OFFICER I CERTI <br />AND AM FY UNDER PENALTY OF LAW THAT I HAVE P <br />FAMILIAR WRH THE INFORMATION SUBMITT ERSONALLY E <br />ED HEREIN; A %AMINED <br />ND BASED I " ~ ~ ' <br />I' TELEPHONE i DATE <br />_ <br />IA h <br />~ h ' ~ ~ <br />~ ON MY INQUIRY OF THOSE INDIVN)UALS IMMEDIATELY RESPONSIBLE FOR <br />TA <br />ING ~7HE I <br />FOR <br />AT <br />O <br />T _ <br />` :' I ~' ~ _'' ~ ~ " i <br />.i <br />~ <br />~/ IN <br />N <br />M <br />ION. I BELIEVE <br />B <br />HE SUBMITTED INFORMATION <br />IS TRUE <br />ACCURATE ANO COMPLETE <br />1 AM AWARE THAT THERE AR <br />SIG 3 ~ ~ <br />l <br />C_ 11 r 1 <br />S - <br />M <br />Y <br />W <br />' , <br />. <br />E <br />NIFICANT PENALTIES FOR SUBMITTING pALSE INFORMATION <br />INCLUDING I -, <br />I.- <br />- "' <br />T, ;cnVl//h 4 <br />.ATA <br />",V~+I G <br />1 <br />_ <br />9 , <br />THE POSSIBILRY OF FINE AND IMPRISONMENT <br />SEE 13 U <br />C <br />1 iWt AND <br />S <br />' <br />L'Ua <br />' p <br />~„ <br />. •: .. <br />. <br />. <br />. <br />C. 1 1a10 <br />7a US <br />lv..orde wdn U'u rrarvta Fur NNvde (I/W . <br />m J(o <br />9W $IGNATUAE OF PRINC AL EXECUTIVE <br />1 $e7S <br />f /~ /D r~Y <br />TYPED OR PRINTED . <br />. <br />. <br />P <br />andnln[Weun 4np•Wmar xTArtneenbmonr.Irand,Jymn./ OFFIC ROR AUTHORIZED AGENT II ~ ;NUMBER YEAR MO DAY <br />COMMENTAND EXPLANATION OF ANY VIOLATIONSfRdmutnPJ/afAeMunvl¢iq '-I ~~, it II I; I ~' I <br />OIL ABD GE2A5°~ St:'L' }'C.'OT9U'f£, P/~":.'10-- UST F.F['CkT L'F EYEt17TIOH5 CL LM°D.n T55 YIIIS~'J DOE! 'itrk08T:;J R'i F:. :. ' <br />TIRES. ;:` "',. I ... ,. '' i. <br />~. .- _ i ~ iiI ; ;. <br />EPA Form ~9241(RBV. &88)PrcYIOUl BOIL/0/ld maybe Ydld. (REPIACESEPA FORM TAO WHICH MAY NOT BE USED.) I ~ li PAGE OF <br />ay;r~. ~.i ()~~3~/i. ~•U 514-1i'J4 ~ <br />