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JUN 12 '96 04:27PM DANA CORP P.6/21 <br />I <br />THIS FORM MIDST ACCOMPANY SAMPLE <br />Profile # Log # <br />J To Be Completed By Generator <br />FCompiany Name: <br />me-L.?' .5 <br />/ %f7c-f< Uentification on Containter: Date: Time: t• Z.3 <br />Sampiing Methoc: niti.Pa r <br />reservation Used: = Y=S (No <br />`'yes, Soecay. ,6 <br />E?A Waste COdes: Y13 L5lJ —irl (—Kpa— <br />— i <br />PROCESS & SAMPLE CERTIFICATION I <br />I certify that I o5tained the sampie of waste material described rn this form and the accompanying GENERATOR'S <br />WASTE PROFILE or was present al or supervised the sampling and that it is a representative sample of the waste <br />stream, and that the representations contained in this document are accurate. <br />Name: Signature: <br />Title: + <br />Data: <br />LAB USE ONLY <br />Received By7 <br />Date: <br />Comments: <br />Time: <br />