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. Apr 05 05 09: 10a Carrie Brown (209) 461 -6342 p. l <br /> by <br /> 0 WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAN&ite IV Contractors. n9TE:1 1 10-5 <br /> ADDRESS:_2535 Wigwam all: AUTHORIZATION #: 7)11 C 17S33�0�10__1 <br /> CITY, STATE:.. FACILITY#AND LOCATION: — a1cc7 <br /> SERVICE REQUESTED: <br /> TANK/l TIGHTNESS TEST V FACILITY INSPECTION ❑ <br /> VAPOR RECCVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER 'K <br /> SERVICES PERFORMED: <br /> Q \ .y <br /> This portion must or-:completed by the field technician each time any work is conducted within a dispenser or tank sump, <br /> even if that work oily--onsis-,s of a visual inveeti n. Fully etacutac copies shoilc be d stributsd as cesignated on the l of each form. <br /> (USE ADDITIONAL FORMS AS NECESSARY) <br /> Li�tbT6.5�ENSOR CONDITION UPON ARRIVAL <br /> Location ID: isp.. ark ID; Location ID: (Disp.#, nk ICI <br /> Location. Sump UD A <br /> / Location: Surn 1 LDC J��y,, ;1� <br /> SansorType: Iv�ochanical ;(Elect�,lhc / NA Sensor Type: Mechanial ElecNA <br /> Located within t'of lowest PcinC_Y.! N / NA Lccated witltin 1'of lavvest Point 1 NA <br /> Is liquid present Y / N quantity: J,J-z� !s liquid present Y / N CLant,ty: ' <br /> Is chain attached to shear,/a!ve Y / N / P A s chain attacher-to shear valve Y ; N PJA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser nel Has sump lid or dispenser Anel <br /> been secured and sealed N/NA been secured and sealed Y N!NA <br /> NJIVSER OF PPSONNEL v` ARRIVAL71MEa kS DPARTURE TIME '3� <br /> 1 TOTAL HOURS (MINUS EA <br /> Pdl NAME NAME OFD ALER/MANA P <br /> SIGN— ATURF SIGNATURE OF DEA ER/MANAGER <br /> DISTRIBUTION:WHITE-Attach to Invoice CANARY.Leave at site PINK-Vendor cony <br /> VVCF-231 i;Oi{,2) <br />