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by #204089 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET N0: � ��1-� DATE: L —Vo- Is <br /> FACILITY NO.&ADDRESS:\9:)�6> L---Q;6-E dot - L!tVR.=f <br /> UellIel"-I'Van inc. <br /> VENDOR NAME&ADDRESS: �'y ti'f05 Sierra Golgi,�aU42 {r <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION ❑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 LEGIBLY <br /> f ..11--�� <br /> -T7� <br /> FEB 12 2-0-18 <br /> Are all sensor(s) locatWLaLt the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> '%k Y ❑ N 'e* b4 >\A ❑ Y ❑ N ❑ Y ❑ N 0 NA <br /> Have all sump lids and dispenser panels bee ❑ECS Notified of liquid found in Vapor equipmen epairs <br /> secured and sealed? '15,Y ❑ N ❑NA 3 � 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 \,D*. DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) 3 <br /> TECHNICIAN PRINT NAYE NA E OF DEA MANAGER <br /> TECHNICIAN URE SIGNATURE OF DEAL ANA <br /> DISTRIBUTION: WHITE- Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />