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ep #2G0881 <br /> Aft 1W WORK ACKNOWLEDGEMENT FORM Ad kk <br /> " <br /> E-MAINTENANCE TICKET NO: ONO DATE: <br /> FACILITY NO.&ADDRESS: W WW3 'bS �•1.oV���Q,, ��Q . <br /> Gettler-Hyart inc. <br /> VENDOR NAME&ADDRESS: S,%1NR •6805 Sierra <br /> SERVICE REQUESTED: Dublin, CA 94568 <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING %DTHER <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 P INT LEGIBL <br /> �v v� v`vn <br /> Nm <br /> tax% s 3 <br /> FEB 12 2018 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑ N DNA U J L) NA J U LI NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? ❑Y ❑ N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ N ❑ NA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME \TA01DM DEPARTURE TIME_\'. <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT ME ME OF DEALER/MANAGER <br /> TECHN ICIIG NATURE SI NATURE OF DEALER/MANAGER <br /> DISTRIf N: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />