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by #204087 <br /> 30 WORK ACKNOWLEDGEMENT FORM „ <br /> IF <br /> E-MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS: t <br /> VENDOR NAME&ADDRESS: n£i05 Sierra Cou-i; Suit61 G <br /> SERVICE REQUESTED: -_ <br /> ❑TANK/UNE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING ❑ OTHER <br /> ❑ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM ❑SUMP NO. ❑UDC/DISPENSER NO. ❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED❑Y ❑N <br /> PLEASE PRINT LEGIBLY } �L d LL t�S v D C- <br /> (S <br /> -- �� — -- <br /> �a <br /> FArellsensor(s) located at the lowest point? Chain attac ed to shear valve? Debris removed from UDC? <br /> ❑ N ❑ NA ❑ Y ❑ N A ❑ Y ❑ ❑ NA <br /> ave all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipme repairs <br /> secured and sealed? -U,Y ❑N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ ❑ NA <br /> NUMBER OF PERSONNEL 1 ARRIVAL TIME n- ? DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT NAME NAME OF DEALER NA <br /> -- <br /> TEC ICIAN SI NATURE OF DEALS GER <br /> DISTRIBUTION: WHITE - Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />