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by <br /> # 192585 <br /> WORK ACKNOWLEDGEMENT FORM;� t t AOL <br /> E-MAINTENANCE TICKET NO; tot 3 z 9 81 DATE; •zZ 5 G " � <br /> FACILITY NO.&ADDRESS: 010j, 4 <br /> Jac <br /> -7j—raul <br /> >/UORI <br /> er- annc. <br /> VENDOR NAME&ADDRESS: s n <br /> SERVICE REQUESTED. 01.11biln, CA 94568 I-tt=myi-t nPPAgTN?1L <br /> Q TANK LINE TIGHTNESS TEST Q FACLITY INSPECTION O ENVIRONMENTAL REPAIRS <br /> 0V POR RECOVERY TEST QSECONDARY CONTAINMENT INO d OTHER <br /> ALARM TYPE AS LISTED ON VEEDER-ROOT P <br /> LOCATON OF ALARM �SMP NO. 4 UDC/DISPENSER NO. 0 ANNULAR TANK NO. <br /> ALL ALARMS CLEARED Y O N <br /> PLEASE PRINT LECi�LY' d� <br /> r <br /> Nni/ 112 <br /> �Ar all sensors)located at the lowest point? Chain attached to hear valve? Debris removed_^fr1oom UDC? <br /> Y Q ONA UY ON 2 0 ❑N Is�NA <br /> Have all sump lids and dispenser panels been O ECS Notilled of liquid bund In Vapor equipment repairs <br /> secured and seated? dY D N C]NA containment sumps documented inRepair Log? <br /> A o*it no sumps or chspensers were aAened. 4 Y O N NA <br /> NUMBER OF PERSONNEL ARRIVAL TIMEDEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> 1lc� r <br /> TECH7 <br /> R EL21LDER !� E <br /> & -.,f , <br /> TE I AN SI TURE SIG E OF AG <br /> NE <br /> D BUTION;WHITE-kwicv copy / CANARY-Site cWy/ PINK Vandar copy <br />