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ARUO,*R <br />n"TROLEUM, <br />Site Name: LIPS -W7 j .Q S -W 7 <br />Site Address: /,(hal <br />rl 9 #X X <br />�// PPE Required (Check all th <br />lJ'Safety Vest ❑Hard Hat <br />❑ Protective Clothing [loves <br />Contractor has discussed job and sal <br />P.O. Box 50' • <br />Vacaville, CA 956: 507 <br />(7071437-6668 (916) 441-2886 <br />TOLL. FREE: t (888) 2ARMOUR <br />[or 1 (888) 227-6687] <br />General Contractor's Lid# 488721 <br />site Phagefi I -M... �J, �'71 / 12j' <br />apps and/or fill-in "other" blank space <br />Steel -Toe Boots L.4Safeq <br />❑ He ring Protection 2rBarric <br />y of bb WAWQ <br />Other <br />W. Signa <br />JSA Refareneep <br />Glasses/Goggles <br />ides/Tape <br />28134 <br />ales Oidera <br />_ <br />te z86 <br />t71 iZ-vI <br />tauona Page <br />rpt .1 <br />❑ COD IILJ Charge <br />Was Job Completed? <br />Ila Yes ❑ No <br />Job Updated/Closed with <br />Customer <br />]Updated 9 Closed <br />Was blue made? <br />❑ Yes <br />How to Reduce or Eliminate Risk <br />Task Step Hazards Not Covered by JSA (Include extra PPE to be wom) <br />oaanentatton requirements <br />tisk - tMs tam may be used as JSA <br />1 RskM <br />ligRisk <br />bir - JSA Raga <br />Risk- JSA Required atl other custioner mqukentents may apply <br />Reported Problem: A� RA—A- "C <br />L-d'QLi1-'� Aw— sit-t—.4f if 44— <br />o! f v4ruL4,,0— s <br />Part # Description Qty Price Amount <br />1�A O7ft3to- Yoh fG die S�ws¢it, 1 <br />Services/Repairs Performed: kv)tx <br />rs't'>04rrl2,,� /- rt- 7 400 , M14412)ft7, -fR- <br />1MV— 70 s1!".j0V CtW49 lit aZUY ¢k.T ftr%,—Ae <br />lt:907- fMIA It1GZ�b jD fatvO 40fy ,,V4 AtAACTU &AAA <br />8'1� <br />Departure <br />Tech Name Arrival Time Time <br />Terms: Please note that some reported problems due <br />to defective equipment or intermittent problems not <br />present or which cannot be duplicated when our <br />Service Technician is on site, may not always be <br />resolved in one trip. <br />It is the customer's responsibility to verify information <br />is accurate on this work order prior to signing form. <br />ZZ51-9,Z <br />06256 b3 uq2js <br />Rental Description " `/ r--"Ej Amount <br />Rentals <br />Latlor Labor& <br />Hours Travel Hours Total Hours Travel Rate Amount <br />A finance charge of 1 112% per month, which is an annual percentage rate of 18%, is charged on all past due accounts. Freight <br />prepaid by seller does not include any' cargo coverage" which is the responsiti ty of the boyar to purchase if needed. In the Total Mileage Charge $ <br />event of efforts orhtgal proceedings to enforce the collection of such sums due herein, customer agrees to pay reasonable <br />adomey'sfe". TOTAL INVOICE... $ <br />1 understand & agree to as terms 6 caafdans aWkmal on tats work order. <br />Sarvk: echntdan int Name) seMce Teehnieien (Pdm Nerve) Autlw MI Parson 1 tint Name) <br />Santee A Ida ' Signature - SOMO Teef kian'a Signature AuYNrred P e Signature <br />PLEASE PAY YNVOICE TERMS *" <br />/IIkl <br />us wwwarmourpetroleum.net <br />ORIGINAL O C PY YELLOW - CUSTOMER COPY PINK - TO REMAIN IN BOOK <br />Total <br />Date <br />g-6 1 <br />