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by #204080 <br /> Aft IW �vv-->- LVS-3 'Nor <br /> WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: ` ���-� DATE: is <br /> FACILITY NO.&ADDRESSA#t>56> FS Ld�l1Si` dot Ll� R=f <br /> ., -r1y aInc. <br /> VENDOR NAME&ADDRESS: �' �'y f''"05 Sierra Court Su'.t :! <br /> SERVICE REQUESTED: Dublin, CA 945568 <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:C-k" '1L' "'b�S -P '� <br /> V-WE'> -'P\ P � r.A " Llt;NA 4-S <br /> ^4'�SS��L� w�► �U..�S w� Gree-��� -����- �IP;L� <br /> Ian <br /> FEB 12 <br /> Are all sensor(s) loca� the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ",Y ❑ NA ❑Y ❑ N dNk, J ❑ N L] NA <br /> Have all sump lids and dispenser panels beep ❑ECS Notified of liquid found in Vapor equipmen epairs <br /> secured and sealed? �Y ❑ N IJNA; � containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑Nom❑ NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME 1-D'- DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) 3 <br /> TECHNICIAN PRINT N E �NA E OF DEA MANAGER <br /> TECHNICIAN SIGNATURE OF DE <br /> RE AL ANA <br /> DISTRIBUTION: WHITE- Invoice copy / CANARY- Site copy/ PINK-Vendor copy <br />