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#bp 7l'�101 <br />vVORK ACKNOWLEDGEMENT FORM <br />E -MAINTENANCE TICKET NO: P, 7�) �3 Q,3J DATE: <br />FACILITY NO. &ADDRESS--. 161 ? 4�1-) - <br />#108464 <br />'AL <br />'IF <br />VENDOR NAME &ADDRESS: �QCldL) f4j-L�A ?�k-D AAALLS <br />SERVICE REQUESTED: I I <br />QTANK/LINE TIGHTNESS TESTbfX-6'UTY INSPECTION Q ENVIRONMENTAL REPAIRS <br />E) VAPOR RECOVERY TEST IJ SECONDARY CONTAINMENT TESTING 13 OTHER <br />IJ ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br />LOCATION OF ALARM USUMP NO. U UDC/DISPENSER NO. U ANNULAR TANK NO. <br />ALL ALARMS CLEARED U Y IZI N <br />PLEASE PRINT LEGIBLY:. <br />Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br />�3-,Y Q N UNA DY ONA Q Y ON kNA <br />eQ <br />Have all sump lids and dispenser panels been 0 ECS Notified of liquid found in Vapor equipment repairs <br />secured and sealed? XY 0 N 0 NA containment sumps documented in Repair Log? <br />only if no sumps or 011sp ensers were opened. U Y IJ N A <br />NUMBER OF PERSONNEL ARRIVAL TIME �Z <br />TOTAL HOURS)(MINUS <br />CIAN PRINT AME NA .,E��(OIDE LE <br />AQ <br />TE;01411\111CIA 1 SIGN SIGNATLJI;E r -- <br />DISTRIBUTION: WHITE - nvoice copy / CANARY - Site copy / PINK - Vendor copy <br />DEPARTURE TIME <br />