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venue 265Po9gsA65m1(olorad X2 HomeOf[e' 6212575th Avenue X4 Merced,CA95341 Commerte(tyCO80022 SilHighway 213WORK ORDER •i,, 967Mabury Road Laveen,AZ85339 (haparral,NM88081 y 6001owa Street 6137 Ed Rh Blvd NE Work Order# SanloSe,(A95133 Redlands,(A Albuquerque,NM87101 • CT 408548-5050P 2010 Mission Road 13600SEAmblerRoad Proposal# $R s'nif 408548-5052F Escondido,(A92029 13722(armetitaRoad 208 Murray oad SE (Ixkama5,OR97015 Date ai 07V 11.0 y Santa FeSpiings,(A90670 Albuquerque.NM 87105 Acct Sales Manager Customer Information Service Request ramal. `b a Name: at b� � a@ y LLC Address: Description:_._..__._._._._._...---.___...._._..._...___._.....______._._..._.__.__..___..._._.__._._.__.._...__._..._._._._._..._._..._..._......_.... f � # € ?poad _ , ....._..._._..._._...._.-......_._._ CA 4x5330 _._._.__.._._._......._..........................._._..................... ___. EPA ID# d ttEA 14 C�..�n�1 ..a .a P Main Contact: ffi .__-_...._. _._ ...__...._....__...__._. Phone: � 5F DAY-81n,2U�.:tFL and CT-R entel _....,-----•_ Secondary Contact: 4-lam$ -_,i.abQr-Clay a A UW 0- Phone: _.__._ _ ..__....._......._. �_...._. -- _M-• ---.__.._.________...._._._._.__.._-.._.._._..... i�= � 4arart �" <tr �atu<i�trtnt 1�vis�C PO# L-525-15 ........._ ..........__.__---.___.___._._._.__.__...._.______._.._.__.____,___._.______...... Materials and Equipment i -EA-F-vie-rigyR aeta'r:fyFan - New Reconditioned -.--... ....... ............... Supplies Metal Poly Fiber Metal Poly Fiber 85-gallon overpack ; ^^ 55-gallon closed top 55-gallon open top _............_.__{_.____._........._._._�--__.._.. .... i 30-gallon closed top I i 30-gallon open top - 20-gallon closed top ...___..�..__.___ Services 20-gallon open top r _ Disposal Services: 15-gallon closed top - Quantityl Container Size Profile#/Waste Type Shipping Document# Treatment Facility 15-gallon open top - �.__.. I__..1:..� ��. '( ------ 10-gallon _--_10-gallon closed top 10-gallon open top 5-gallon closed top i 5-gallon open top -_._.._.__r_..____.�.._•--._._._.._-- ._.._._...._.. 1-gallon open top ....... _----•-- PIH Packaging __.,. _ ____ _..._.- -_-_--• --- -- `--- "-------�-- --____-•_-N___y_ --�—__..-- _ _._ .._.._ 275-gallon tote ___..__._._._.___�.-....................... __.__... Cubic Yard Box 4ftLight Tube Drum _.____- - --___. .._____ __ ____.__-_._.__;._______.--.-- - ---_-•.--_--.__.�_.__._ ._..__ _____._._.__._.Y__--.---. Sit Light Tube Drum ; !-~- Packing Materials # Transportation Services: Vermiculite,Bag –_—_ -- Number of Containers Facility/Destination Clay Absorbent,Bag ._._._._.._.__.._- Bubble Wrap,Roll Bubble Wrap Bags,Box DrumLiners __._.___.__._._...---_-_--_•- - _ _ .— - _. ___.___ _____.__._. .-.------...___..__._.._.__._.___-. Pallet SuperSack - M1--- _ Notes: Radioactive Waste Boxes Biological Waste Boxesoo�' Red Biological Waste Bags Labor: Hours/Regular Hours/Overtime Service Provided Personal Protective Equipment # Protect Manger Chemist Level D Technician Level C _. _.-_--.-- Driver LevelB _...._...........__.�Zt _•-•_-._.___.....__.--.....-•--_,_._._.___.__. _..__._____._.__...__._._._._____.___._._._._._.._.--•---._._._. Other: , r Other Materials # Notes: Customer Signature: {LGJ� A.�:l" Date:��) ........ ----------- -------...... PRINT NAME: