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• <br />40 <br />I FOR THE YEAR ENDED DECEMBER 31,19— PAGE 1 <br />2 COMPANY NAME: <br />3 COMPANY ADDRESS: <br />a <br />s COMPANY PHONE NUMBER: <br />6 UTILITY SERVICE(S) PROVIDED: WATER SEWER (Circle areas) <br />NAME, ADDRESS, AND PHONE NUMBER OF PERSON(S) TO CONTACT CONCERNING <br />INFORMATION CONTAINED IN THIS REPORT: <br />7 <br />9 <br />10 <br />II <br />12 <br />13 <br />NAME, ADDRESS, AND PHONE NUMBER OF PERSON(S) TO CONTACT CONCERNING <br />PLANT OPERATIONS: <br />14 <br />Is <br />16 <br />17 <br />i9 <br />19 <br />23 <br />CERTIFICATION <br />I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN AND ATTACHED TO <br />THIS ANNUAL REPORT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND <br />BELIEF. <br />21 DATE: TITLE: <br />22 SIGNATURE: <br />WI.12.82 <br />