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by ,� D 7 �S #204617 <br /> 1W WORK ACKNOWLEDGEMENT FORM ' <br /> hl_C % <br /> E-MAINTENANCETICKETNO: �QI bb �J DATE: /) 7 ✓ MI <br /> FACILITY NO.&ADDRESS: Gettler-Ryan Inc. <br /> — 66Ub Sierra Court, ulte G <br /> VENDOR NAME&ADDRESS: Dublin <br /> . CA 945sR <br /> SERVICE REQUESTED: <br /> ❑TANK/LINETIGHTNESS 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❑IY ❑N <br /> PLEASE PRINT LEGIBLY s l -- h ✓v�� <br /> , <br /> ' Gc / �, OtC' ✓�� N <br /> L'1.11_111� ✓"T„ v�� , we, . <br /> 1 <br /> l <br /> nrr'n fl2 017 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> U ❑ N ❑NA U J ❑ 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 / G/ y DEPARTURE TIME J J ) <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT N _ NAM F DEALER/MANAGER <br /> CHNTcIAN S"IGNATURE SIGN T O DEA /MANAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />