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# 192585 <br /> by Aj6L <br /> WORK ACKNOWLEDGEMENT FORIMPP <br /> , , AppqJEN'T <br /> v-r9 <br /> E MAINTENANCE TICKET NO: 10152-M DATE: ........ -91 E F.::D <br /> FACILITY NO.&ADDRESS: vel 020v -7�atv 3 iTlz,,�t 0 <br /> - -FYI N18 <br /> VENDOR NAME&ADDRESS: 680!i&2elltler (yan nc.Siel= NTAL <br /> tv 1�7 <br /> SERVICE REQUESTED: L)Ublin, CA <br /> 94568 <br /> C)TANK/UNE TIGHTNESS TEST U FACILITY INSPECTION U ENVIRONMENTAL REPAIRS <br /> CIV PORRECOVERYTEST C1 SECONDARY CONTAINMENT TESTING U OTHER <br /> d.\ , )14 tlAvp L <br /> 7ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL O,/J,42;2 L <br /> LOCATION OF ALARM �/PSOMP NO. 4-5 C3 UDC/DISPENSER ANNULAR TANK NO. <br /> ALL ALARMS CLEARED�dY C1 N <br /> PLEASE PRINT LEGIB V-• 8 /,IS Sel <br /> e3 <br /> Noll 9 -7nii( <br /> 1W <br /> All <br /> 20 <br /> Are all sensor(s)located at the lowest point? Chain attachedt shear valve? Debris removed from UDC? <br /> td� LIN Q NA 0 Y UN 2NA Q Y L)N UINA <br /> Have all sump lids and dip enser panels been Ck ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? 0 Y E)N Ck NA containment sumps documented in Repair Log? <br /> rA only if no sumps or dispensers were opened. Q Y Cl l::i7NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME 572a,41 DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS <br /> A <br /> W <br /> TECH RINT <br /> E NA F DEALAN GE <br /> TECH PICtAN SIGNATURE SIG OF DEALERNANAGEW\,,� <br /> DIST4BUTION;WHITE-Invoice copy CANARY-Site copy PINK-Vendor copy <br />