Document 2j6dyKMpxmYOMbBmDeZpLBa17

Georgia Environmental Protection Division GEORGIA ANNUAL HAZARDOUS WASTE REPORT Reporting Period January 1 thru December 31, 1983 FORM A IDENTIFICATION Please print/type with Elite type (12 characters per inch) I. EPA I.D. NUMBER GA II. NAME OF INSTALLATION III.INSTALLATION MAILING ADDRESS Street or P.O.Box City or Town State Zip Code IV. LOCATION OF INSTALLATION (if different than Section III. above) Street or Route Number City or Town. County V. INSTALLATION CONTACT State Zip Code Name (last and firstT Phone No. (Area code & number) VI. PROCESS IN USE (Check as appropriate) sqG GEN TUN T01 T02 TO 3 TOA SOI S02 SO 3 SOA D80 D81 D83 __ PRIVATE (Handle only self " __ COMMERCIAL (Handle waste generated waste) generated from other sources) VII.CERTIFICATION - I certify under penalty of Law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information. I believe that the submitted information is true, accurate, and.complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. Print/Type Name & Title Signature of Authorized Representative Date Signed Page 1 of SCI 03036