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AMEX TRANS# <br /> j ARCO PRODUCTS COMPANY <br /> E H&S INSPECTION PROGRAM WORK ACKNOWLEDGMENT <br /> VENDOR NAME - Sc 07'?" L_ o r- C'A_ DATE 1 --214-o2001 <br /> ADDRESS - 717 Dz /T j L E pk- AUTH# <br /> CITY, STATE 917AJ j :A rJ b f2,Q CA_ FACILITY# O V9-3,R- <br /> LOCATION <br /> 93,R-LOCATION /,h E. ZI A k-D/&[r (A V_ <br /> 7'-OC K r10 Atn - . <br /> SERVICE REQUESTED (CHECK) <br /> TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS <br /> OTHER ❑ <br /> SERVICES PERFORMED (REPAIRS ONLY) WA 7 e' �� <br /> MATCRcA< L( <br /> SE c= S� SAL �1PcJM <br /> NUMBER OF PERSONNEL—/ TOTAL TRAVEL TIME 2 BLESS MEAL TIME <br /> Ld <br /> CHECK IN CHECK OUT n <br /> ARRIVALS AS OF CHECK IN Etoo 0 PM DEPARTURES AS OF CHECK OUT '7 PM <br /> PRINTED NAME OF DEALER PRINTED NAME OF DEALER <br /> OR STORE EMPLOYEE OR STORE EMPLOYEE <br /> DATE - DATE <br /> SIGNATUR F DEALER OR STORE EMPLOYEE SIGNATU,$ <br /> liE OF DEALER OR STORE EMPLOYEE <br /> r <br /> SIGNATURE OF DEALER(OR STORE MANAGER)DOES NOT OBLIGATE DEALER IN ANY WAY,NOR DOES IT <br /> SIGNIFY ANY APPROVAL OF WORK DONE.CONTRACTOR IS RESPONSIBLE FOR FILLING OUT THIS FORM <br /> AND OBTAINING SIGNATURE. <br /> VENDOR COPY <br /> APC-3321(7-97) <br /> a. <br />