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by #200880 <br /> 44", WORK ACKNOWLEDGEMENT FORM AL" <br /> E-MAINTENANCE TICKET NO: lutxMV DATE: Z u 4re_) <br /> FACILITY NO.&ADDRESS: kV IV,. <br /> VENDOR NAME&ADDRESS: Q� VAC <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION U ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING OTHER <br /> ❑ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM ❑SUMP NO. ❑UDC/DISPENSER NO. ❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED❑Y ❑N <br /> PLEASE PRINT LEG LY 0� �G�1�. N .�G �N MW S%7 Vi 4 <br /> •� _ Q. <br /> sa <br /> iVt i ikdft <br /> �s a •Ssa <br /> r�cr_�t\/FD <br /> FEB 12 2018 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑ N DNA 0 U ❑NA ❑ Y UN ❑ NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? ❑Y ❑N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑N ❑ NA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME : O DEPARTURE TIME <br /> NN�� <br /> TOTAL HOURS (MINUS MEALS) AL'S <br /> %Cj qn 5Qt <br /> TECHNICIAN PRINT ME NAME OF DEACLEWMApJAGER <br /> TECHNICIA GNA RE SIGNATURE OF/DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />