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Nov 09 05 03: 02p Carrie Brown (2091 461 -6342 p. 1 <br /> by <br /> WORK ACKNOWLEDGEMENT FORUM <br /> VENDOR NOte y QDnf�';ftCtorc DATE' <br /> ADDRESS:2535 Wigwam I)r, AUTHORIZATION #: <br /> OIC, . 95205 FACILITY#AND LOCATION: <br /> CITY, STATE: <br /> SERVICE REQUESTED: <br /> TANK,ILINE TIGHTNESS TEST ] FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER x <br /> SERVICES PERFORMED; <br /> a' <br /> This portion mus`be cornc'leted by the field technician sect,-ime any work,s conducted within a dispenser or tank sump, <br /> even If that work orly orsists of a visual inspection. Fully executed copies shou d be distributed as aes gnated on tine x1torr of each.form. <br /> (USE ADDITIONAL FORMS AS NECESSARYI <br /> �. L19,UID SENSOR CONDITION UPON ARRIVAL <br /> ' Location ID' (Qisp.'f.Task ID) <br /> ID <br /> -ocation ' <br /> Location' ump UDC r Annular <br /> Location: Sumo / UDC / Annular <br /> Serscr Type: echanical / E,eetronic / NA <br /> Sensor Type Mechanical Electronic / hA <br /> Lccated w-thin 1"of lowest Point Y / N / NA <br /> Located within 1"of lowest Pant Y ( N ,+ NA <br /> 15 liquid present Y ! N quantity: <br /> Is liquid present Y / N Quantity: <br /> is chain attached to shear valve Y ,' N ; NA <br /> Is chain attacned to Shear valva Y / N / NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sumo I,d >r dispenser pane' <br /> yas sump lid or dispenser panel <br /> ,� � Dean secured and sealed Y/N/NA <br /> been secured and sealed IY/N/NA Cy <br /> NUPf6ER OF PERSONNEL ARRIVAL TIME �•J --DEPAP.TURE TIME <br /> TOTAL HOURS MINUS MEALS) <br /> PRINT NAM I I�fAME OF DEAL / ANAGER <br /> T rte M� I qt <br /> r � / IGN R F EALER ANAGER <br /> SIGNlURE <br /> DISTRIBUTION: wHrrE•Attwh to irwice CANARY-Lino Oahe PINK•Vendor copy <br /> WC-P33'a W-W) <br />