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ARCO Products Company j[ WORK ACVNOWLEDGMENT A940884 <br /> Belslilre hnvi�ol�=r. <br /> VENDOR NAME DATE. 1 <br /> ADDRESS . X422 I'rabuco Road#105-269 FACILITY#: 1493` AUTH#/JOB ORDER:- penchrig <br /> ake Forest .6 East 1-Tai�ding Way <br /> CITY LOCATION: <br /> STATE, ZIP CODE CA 92630 Stocktoll C.` <br /> SERVICE REQUESTED: <br /> Belshire is requested to remove drum(s j of maste containing petroleum I:ydrocarbons. <br /> SERVICES ACTUALLY PERFORMED: Irientifit, t-1 e: min1her ofdrums, removed fi-oni the <br /> Gasoline/Water drums: <br /> Absorbent/Gasoline Filter drums: <br /> Waste Gil drums,- <br /> Empty <br /> rams:Empty drums. <br /> Did you transfer waste? (Circle One) YES / NO If yes, explain: <br /> PARTS: Materials used on site: 6 <br /> Number of bags of absorbent: <br /> 'Number of 85 gallon overpack drums: <br /> Number of new 55 gallon drums: <br /> Did you leave waste on site? (Circle One) YES NO If yes, exVlaitl: <br /> LABORTOTAL TRAVEL <br /> 0� ARRIVALs At OF LESS MEALTIME TOTAL <br /> AM AM <br /> pM <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 { rl <br /> F ED NAME OF DEALER <br /> Cis ORE MANAGER/EMPLOYEE: DATE: <br /> • f ` <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 />