Document JrmaDyGe9g20RBg2kedDbryLX

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 A D O O O <o O II. NAME OF INSTALLATION III. INSTALLATION MAILING ADDRESS 40 30_FLA _________ Street or P.O.Box _ _____________________________ 2Q34o______ City or Town State Zip Code IV. LOCATION OF INSTALLATION (if different than Section III. above) Street or Route Number City or Town State County V. INSTALLATION CONTACT E i L_ _J OHC_ Name (last and firstj ^ 4o4z44S-_a2Li Phone No. (Area code & number) VI. PROCESS IN USE (Check aa appropriate) Zip Code 3QG GEN TRN T01 T02 TO 3 T04 SOI S02 S03 S04 D80 D81 D83 y/ yS 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 _LPage _1_ of SCI 03031