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Ar"rX TRANS# <br /> j ARCO PRODUCTS COMPANY <br /> E H&S INSPECTION PROGRAM WORK ACKNOWLEDGMENT <br /> VENDOR NAME (-7 tG i } DATE ,~ �Z-- <br /> ADDRESS AUTH# <br /> CITY, STATE FACILITY# <br /> LOCATION ' Lr7 <br /> c�TCC��"-Lys Ufa <br /> SERVICE REQUESTED (CHECK) <br /> TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER <br /> SERVICES PERFORMED (REPAIRS ONLY) <br /> to - Ocn te<- hc"J !r� J o,ce p, <br /> t4 <br /> NUMBER OF PERSONNELTOTAL TRAVEL TTME ` LESS MEAL TIME <br /> CHECK IN CHECK OUT <br /> ARRIVALS AS OF CHECK IN AM PN DEPARTURES AS OF CHECK OUT L SU AN�PN <br /> PRINTED NAME OF DEALER PRINTED NAME OF DEALER <br /> OR STORE EMPLOYEE OR STORE EMPLOYEE <br /> _ DATE DATE <br /> SIGNATURE OF( EAI,ER O TORE EMPLOYEE SIGNATUR OF ER,.OI�STORE EMPLOYEE <br /> SIGNATURE OF DEALER(OR STORE MANAGER)DOES NOT OBLIGATE DU<CER IN ANY WAY, R DOES IT <br /> SIGNIFY ANY APPROVAL OF WORK DONE.CONTRACTOR IS RESPONSIBLE FOR FILLING OUT T S FORM <br /> AND OBTAINING SIGNATURE. <br /> LOCATION COPY <br /> APC-3321(7-97) <br />