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by #204. <br /> 34 <br /> 4M111W WORK ACKNOWLEDGEMENT FORM <br /> MAR 19 2018 Nor <br /> E-MAINTENANCE TICKET NO: /cl/,3 (►Co 7 3 DATE: /l S 17 <br /> ttl r- an I <br /> FACILITY NO.&ADDRESS6j ; � E Ga uisEr L1 UCf l .ea-r-erfie�P <br /> VENDOR NAME&ADDRESS: Dublin, CA 94568 <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESSTEST ❑FACILITY INSPECT ON ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING ❑ OTHER <br /> '12ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL S It N <br /> LOCATION OF ALARM ❑SUMP NO. ❑ UDC/DISPENSER NO. ❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED�!NY ❑N <br /> PTPRINT LEGIBLY_ 5�T' 0? <br /> 1F�,�rr sib s - sQ,e - fri��n SAN so <br /> Ate— ALi2f de6A)-Cn(' dy S <br /> ,moo 41el'51c 41&,Ze-s a jAcd'--j A-2 6 �'r t� �. ,c�,oa�oc.as w t'7- <br /> EGL-*Jp TtForr Tf&- Z iP-� 2 5c-o-JSo,e f3o -i- $-flucr�/ <br /> S Eiur 0 CNtiJ -5 tfA.) wfs►-tL <br /> • �IZ?-5 IV�D�t� Oa �3� m,ev�c'D r3Y Dt�Nt� <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> Q Q �MA ❑ Y Q k4NA J ❑ NrELNA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? F ' ❑ N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ N SNA <br /> NUMBER OF PERSONNEL ARRIVAL TIME DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICI PRINT N M NAME OF DEALER/MANAGER <br /> Tec)qMMAN SIG RE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />