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B01 9P-70 <br /> by <br /> SEE W. WORK ACKNOWLE7� 6 <br /> EMENT FORM <br /> 1 <br /> VENDOR NAME: Belshire Environmental DATE: 9ESINumber: 58931 <br /> ADDRESS: 25422 Trabuco Road #1 US''69AUTHORIZATI�N #: 'r 1925889 <br /> CITY, STATE: Lake Forest CA 92630 FACILITY#AND LOCATION:4932 <br /> 16 East Harding Way <br /> Stockton C.A. <br /> SERVICE REQUESTED: <br /> TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER N Belshire is requested to remove 1 drum(s)of waste containuig petroleum hydrocarbons. <br /> SERVICES PERFORMED: Idei0tify the number of drums removedin the site: <br /> (lasolinetWater dntms- y Wnste f)il drums.-C> <br /> Absorbent/Gasoline Filter dtnm,,Q Em1)ty drij s'--It2 <br /> Did you transfer waste? (Circle One) YES 09P If yes, explain: <br /> Materials used on site: <br /> Number of bags of absorbent: Number of 85 gallon overpack drums-6_3>Number of new 55 gallon drums <br /> Did you leave waste on site? (Circle One) YES CNY._7_-> 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) <br /> LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location ID: (Disp.#,Tank ID) Location ID: (Disp.#,Tank ID) <br /> Location: Sump / UDC / Annular Location: Sump / UDC / Annular <br /> Sensor Type: Mechanical / Electronic / NA Sensor Type: Mechanical / Electronic / NA <br /> Located within 1'of lowest Point Y / N / NA Located within I"of lowest Point Y / N / NA <br /> Is liquid present Y / N Quantity: Is liquid present Y / N Quantity: <br /> Is chain attached to shear valve Y / N / NA Is chain attached to shear valve Y / N / NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser panel Has sump lid or disp.enser panel <br /> been secured and sealed Y/N/NA been secured and s9led Y/N/NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME 1J DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> PRINT NAME NAME OF DEALER/MANAGER <br /> > 1. <br /> SIGNATURE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Attach to invoice CANARY-Leave at site BLUE-BPWCP Compliance copy PINK-Vendor copy <br /> WCP-3316(07-02) u <br />