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bp. #200555 <br /> WORK ACKNOWLEDGEMENT FORM <br /> MAR' 7 9 ^018 \/ <br /> E-MAINTENANCE TICKET NO: ����O�o13 DATE: —'\—I�a <br /> FACILITY NO.&ADDRESS*\Jq'=) <br /> VENDOR NAME&ADDRESS: C — p•—i G-Miler-Ryan Inc. <br /> SERVICE REQUESTED: ''�lylifi, CA 94568 <br /> ❑TAN K/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❑Y ❑N <br /> PLEASE PRINT LEGIBLY: <br /> yt1���-'E �--� S�-� ��x S—�L �k;� fit, ��►,,o„�. <br /> RECO IA N .5L 2n <br /> i <br /> Are all sensor(s) located at the lowest point? Chain attache o shear valve? Debris removed from UDC? <br /> Y ❑ N ❑ NAQV .STV ❑ Y D UNkj ❑ ❑ NA <br /> Have all sump lids anti dispenser panels, en ❑ECS Notified of liqui found in Vapor equipme'nt repairs <br /> secured and sealed? Y ❑ N ❑NA I S- 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 DEPARTURE TIME 3 " <br /> TOTAL HOURS (MINUS MEALS) <br /> G0 <br /> TECHNICIAN PRINT NAME NAME OF DEALER/MANAGE <br /> TECHNICIAN SIGNATURE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />