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SUN 12 '96 04:2SPM DANA CORP <br />THIS FORM MUST ACCOMPANY SAMPLE <br />Profile # <br />Company Name: <br />Address: <br />To Be Completed By Generator <br />0—t (Ln U <br />Sample Identification on Containtar: M.f. <br />Collection Date: e° -Ll,.. 4 <br />Sampling Melhoc: ^� <br />Preservation Used: _ Y9s 4lvo <br />'! Yes. SoeC,nJ <br />_esCr;zT:cn D! �--=es5 l]anarZ [In. 1":erste Srr='. S <br />EPA Waste Codes: 11L�02---00081 <br />f h1U. (— <br />Log <br />PROCES$ $ SAMPLE CERTIFICATION <br />P. 9.'21 <br />Time: 1 fi( <br />N <br />I certify that I obtained the sample of waste material described in this form and the accompanying GENERATOR'S <br />WASTE PROFILE or was present at or=upervised the sampling and that if is a representative Ot the waste <br />stream, and that the, du contained in this document are accurate. <br />Name: 14 6V AVA",O Signature: <br />Title: S V (-17:6,-7-- Date: L 7 <br />LAB USE ONLY <br />Received By: <br />Date: Time: <br />Comments: <br />