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B 59 <br /> by <br /> "1 WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAME: Belshire Environmental DATE: <br /> BESI Number: 61914 <br /> ADDRESS: 25422 Trabuco Road#105-269AUTHORIZATION #: <br /> pending <br /> CITY, STATE: Lake Forest CA 92630 FACILITY#AND LOCATION:4932 <br /> 16 East Harding Way <br /> Stockton CA <br /> SERVICE REQUESTED: <br /> TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST F1ENVIRONMENTAL REPAIRS El <br /> OTHER C r g petroleum hydrocarbons. <br /> SERVICES PERFORMED: the S;Itea' <br /> ry <br /> AT <br /> on site: <br /> MatefiaLused <br /> a <br /> Number of bags of absorbent: Number of 85 gallon overpack drums: Number of neve 55 gallon drums: <br /> IDid you leave Waste on site? (Circle One) YES O If yes, explain: <br /> This portion must be completed by the field technician each time any work is conducted within a dispenser or tank sump, <br /> even if that work only consists of a visual inspection. Fully executed copies should be distributed as designated on the bottom of each form. <br /> (USE ADDITIONAL FORMS AS NECESSARY) mo-. <br /> LIQUID SENSOR CONDITION UPON ARRIVAL (Disp.#,Tank ID) <br /> Location ID: <br /> (Disp.#,Tank ID) Location ID: <br /> Sump / UDC Annular <br /> Location: Sump / UDC / Annular <br /> / <br /> Location: <br /> ;. Sensor Type: Mechanical / Electronic / NA <br /> Sensor Type: Mechanical / Electronic / NA <br /> Located within 1'of lowest Point Y / N / NA Located within 1'of lowest Point Y / N / NA <br /> Is liquid present Y / N Quantity: <br /> Is liquid present Y / N Quantity: <br /> Q ' Is chain attached to shear valve Y / N / NA <br /> Is chain attached to shear valve Y / N / NA <br /> a .. <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser panel <br /> p Has sump lid or dispenser panel <br /> been secured and sealed Y/NJ NA <br /> Qbeen secured and sealed Y!N/NA r <br /> V DEPARTURE TIME <br /> Z NUMBER OF PERSONNEL ARRIVAL TIME <br /> ,NOTAL HOURS (MINUS_ —'— <br /> r <br /> 1 NAME OF D ALE MANA <br /> _oRINT E <br /> TUBE SIGNATURE OF DEALER/MANAGER <br /> "JHITE-Attach to invoice CANARY-Leave at site PINK-vendor copy. <br />