Document k6meg6kezeoeKBp1DLZxQVZ5b

I Georgia Environmental Protection Division GEORGIA BIENNIAL HAZARDOUS WASTE REPORT Reporting Period January 1 thru December 31, 1985 FORM A IDENTIFICATION Please print/type with Elite type (12 characters per inch) I. EPA l.D. NUMBER GA II. NAME OF INSTALLATION III. INSTALLATION MAILING ADDRESS StFeet-oF F.C.~Box CiFy-oF Town SFaFe Zip Code IV. LOCATION OF INSTALLATION (if different than Section III. above) Street-oF RoutF Number City or Town SFaFe Zip Code County V. INSTALLATION CONTACT Name (last-and-first) Phone NoT TAFelf Cb3e~V~Number) VI. PROCESS IN USE (Check as appropriate) NHD SQG GEN TRN TOl T02 TQ3 TO4 SOI SQ2 S03 SQ4 D80 D81 P8I Date on which NHD or SQG status was granted: ____PRIVATE (Handle only selfgenerated waste) ____COMMERCIAL (Handle waste generated from other sources) VII. SIC CODE VIII. 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 03059