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5 LIJ401C <br /> by 0 <br /> WORK ACKNOWLEDGEMENT FORM <br /> C) vEND Elite IV Contractors, Inc. DATE: / � S US <br /> ADDRES on�B905AIJTH ' N # SSZ- <br /> CITY, STATE: l/3 F{fA-CI A LOCATION: V 2 q <br /> SERVICE REQUESTED: <br /> TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST �[ ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER ,1 <br /> SERVICES P FORMED:JQ �l-��T <br /> r <br /> �4 r , <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 if visual inspection. Fully executed copies should be distributed as designated on the bottom of each form. <br /> (USE ADDITIONAL FORMS AS NECESSARY) <br /> "j"' LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location ID: /5/ (Disp.#,Tank ID) Location ID: i14 (Disp.#,Tank ID) <br /> Locatic Sump UDC / Location: Sump / U C /'Annular <br /> Sen sor Type: Mechanic / Electronic / NA Sensor Type: Mechanical / Electronic / NA <br /> Located within 1'of Iowa t Poi Y / N / NA Located within 1'of lowest Point Y / N / NA <br /> Is liquid present YDuantity: Is liquid present Y / N Quantity: <br /> Is chain attached to shear valve Y / N A Is chain attached to shear valve Y / N / NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser pan Has sump lid or dispenser panel <br /> Il <br /> been secured and seal Y/ /NA �2been secured and sealed Y/N/NA <br /> NUMBER OF PERSONNEL ' ARRIVAL TIME 76u DEPARTURE TIME_- <br /> r} TOTAL HOURS (MINUS MEALS) <br /> PRINT NAI E OF D&OFDEALE <br /> ANAGER <br /> SIGNATU E tAT RE b1ANA <br /> DISTRIBUTION: WNRE-Attach to invoice CANARY-Leave at site BLUE-BPWCP Compliance copy PINK-Vendor copy <br /> WCP3316(07-02) <br />