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ARCO Products Company �% WORK ACKNOWLEDGMENT A <br /> Bjelslvre isiMronr, ! SarviGes__lac. B.11--,ST?�T�tm'r <br /> VENDOR NAME DATE: <br /> ?5422 1`rabuco Roar.#1035-269 4932 <br /> ADDRESS FACILITY#: AUTH#/JOB ORDER: <br /> CITY Lake Forest LOCATION: 16 Fast Harding 17`,iay <br /> CA 92630 Stoch-ton <br /> STATE, ZIP CODE <br /> SERVICE REQUESTED: <br /> Belshire is requested to remove 1 drum(s)of waste containing petroleum hydrocarbons. <br /> SERVICES ACTUALLY PERFORMED: ;dent1A` the in-un11 er of tit.mns ret71oved ,,ton, The site- <br /> J <br /> GasolinetWater drams: <br /> Absorbent/Gasoline Filter drums: <br /> Waste(:;il dsumc: <br /> Empty drums. <br /> Laid you transfer waste? (Circle One) YES (94 If_yes, explain: <br /> PARTS: Materials used on site: �{ <br /> Number of bags of absorbent: <br /> Number of 85 gallon overpack do ms-. (U <br /> Ntmber of new 55 gallon drums: <br /> Did you leave waste on site? (Circle One) YES (` T if 1"e's, exulain: <br /> LABORNUMBER OF ARRIIVALs� TOTAL TRAVEL LESS MEALTIME TOTAL <br /> PERSONNEL CHECKIN 11�14 TIME <br /> AM y AM <br /> M f PM <br /> "t <br /> FOR NON-LESSEE/CONTRACT DEALER USE ONLY. FACILITY STAMP <br /> ❑ MAINTENANCE VENDOR (Attach white copy to invoice and mail to technician.) <br /> ❑ LIGHTING <br /> ❑ LANDSCAPING / FLOOR/PEST CONTROL VENDOR <br /> ❑ FIXED COST (Dispensers, General Contractor, Signage) <br /> TOTAL <br /> F- 'TED NAME OF DEALER <br /> ;TORE MANAGER/EMPLOYEE: DATE: <br /> SIGNATURE OF DEALER <br /> OR STORE MANAGER/EMPLOYEE: <br /> SIGNATURE OF DEALER (OR STORE MANAGER) DOES NOT OBLIGATE DEALER IN ANY WAY, NOR DOES IT SIGNIFY ANY APPROVAL OF WORK <br /> DONE. CONTRACTOR IS RESPONSIBLE FOR FILLING OUT THIS FORM AND OBTAINING SIGNATURE. <br /> A Dr` 0010 /vA-1 ---- -- %A-- <br />