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by #200880 <br /> 1�200�5� <br /> WORK ACKNOWLEDGEMENT FORM AL <br /> IF <br /> E-MAINTENANCE TICKET NO: kt SAjV DATE: CLIVI Iiia <br /> FACILITY NO.&ADDRESS: �QODO Q)S �. 1��Q� +lV Q,• U&0 n ,(A- <br /> VENDOR NAME&ADDRESS: V\ V\C <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE 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 LEG LY� R A� \v,l 9 A <br /> • C a a <br /> IJ 1A <br /> ED <br /> FEB 12 2010 <br /> Are all sensor(s)located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑ N ❑ NA ❑ Y ❑N LINA ❑ Y ❑ N IJ 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 PERSONNELARRIVAL TIME O DEPARTURE TIME O <br /> x TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT ME NA J�=L/�IMA�AGER <br /> TECH NICIA GNA RE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />