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JUN 12 '96 04:29PN DRNR CORP <br />THIS FORM MUST ACCOMPANY SAMPLE <br />Profile * <br />Company Name:P— V _ <br />Address: 9l to <br />To Be Completed By Generator <br />�r. <br />P. 1221 <br />S i�c ra.J OA <br />Sample Identification on Contaimee M t s <br />Collection Date: - 6— C{– J7 � Time: ii <br />Sam piing Methacr <br />Preservation Msec- 7 YES XNO <br />.` Yes scec! <br />EPA Waste Codes: b co rS <br />PROCESS & SAMPLE CESTIFICATION <br />f certify that I obtained the sample of waste material described in this form and the accompanying GENE'RATOR'S <br />WASTE PROFILE or was present at cr supervised the sampling and that it i seMat! sample 1 the waste <br />Stream, and that the representations contained in this document are accurate. �./� <br />Name: �2 �Un� 5 Signature: cv�' <br />Title: u rj aq— Date: W6 V <br />LAB USE ONLY <br />Received By: <br />Dale: Time: <br />Comments: <br />