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by #204087 <br /> tl> 1%e','--�7%k5ar WORK ACKNOWLEDGEMENT FORM " <br /> `r <br /> &MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS:V1b Y, c65 F- • Lc:,v1S le L l�111 <br /> VENDOR NAME&ADDRESS: 6; �.�p,• 6,905 S-iert'a "'out', quit+✓ <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+❑YY❑N r <br /> PLEASE PRINT LEGIBLY `�` p'LL, I S t Q- 1 10 <br /> � dT L i�►.n b �,.s�.S �! ��Z Liu� L►11-� �R►'--� �j c�L�"r��../ <br /> RECEIVtO <br /> FEB 12 2010 <br /> Are all sensor(s) located at the lowest point? Chain attac ed to shear valve? Debris removed from UDC? <br /> Y U ❑ NA U U A U ❑ ❑ NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipmerV repairs <br /> secured and sealed?-6J.Y ❑N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ ❑ NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME �- ?"� DEPARTURE TIME <br /> j TOTAL HOURS (MINUS MEALS) <br /> /� <br /> lel, �l <br /> TECHNICIAN PRINT NAME NA E OF DEAL! NA <br /> TEC ICIAN AnTL Re SIGNATURE OF DEALEUdAWAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />