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' 2009 02/06 12:48 FAX X001 <br /> 1 . <br /> BNH BUSINESS PORMS(714)070.0025 8593144 <br /> by # 32011 <br /> AL <br /> WORK WORK ACKNOWLEDGEMENT FORM <br /> E-MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS: S-E_ L� c-+< <br /> VEND R NAME&ADDRESS: <br /> SE VICE REQUESTED: <br /> TANKILINE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENTTESTING Q OTHER <br /> Q ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM ❑,SUMP NO. CI UDC/DISPENSER N0. ❑ANNULAR TANK NO, <br /> ALL ALARMS CLEARED Y ❑N <br /> PLEASE PRINT LEGIBLY <br /> Are all sensor( )located at the lowest point? Chain attached t shear valve? Debris removeEairs <br /> lJY ❑N NA _ ❑Y ❑ N NA ❑Y UN <br /> Have all sump lids and d• penser panels been Q ECS Notified of liquid found in Vapor equipmesecured and sealed? IY ❑N EINA containment sumps documented InA only if no sumps or dispensers were opened. C�Y IJ N 11 <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME \\ D� DEPARTURE TIME <br /> C.y <br /> �,. TOTAL HOURS (MINUS MEALS) � i) <br /> --` - E I c <br /> TEt:HNI <br /> NA E OF DEALER/MANAGER <br /> T NIC A SIG IGNATUFIE O LA213/10ANAGER <br /> DISTRIBUTION:WHITE-Involce copy / CANARY-Site copy/ PINK-vendor copy <br />