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#200881 <br /> by `�'�-��4 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> `or <br /> E-MAINTENANCE TICKET NO: \O`S\O l.1 DATE: <br /> FACILITY NO.&ADDRESS: WbOVO 'bS C�.�,Oy��� ��Q,• . <br /> Geffler-Hyark Inc. <br /> VENDOR NAME&ADDRESS: •6805 SI <br /> SERVICE REQUESTED: ublin, CA 94568 <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING 0,pTHER <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 P INT LEGIBL W v►�Q ISN \I3 �C1�F� <br /> MV�hlll <br /> 79+A ;. 1.0 <br /> M\�ar�S• S 3 <br /> Q�W � <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 LINA ❑ Y D ❑ NA ❑ Y ❑ N ❑ 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 �L \O DEPARTURE TIME v �(Y1 <br /> X N TOTAL HOURS (MINUS MEALS) <br /> JAS <br /> ,) <br /> TECHNICIAN PRINT ME ME OF DEALER/MANAGER <br /> TECHNICI IGNATURE SI NATURE OF DEALER/MANAGER <br /> DISTRIBU N:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />