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ep lag m Ik513 ,�j 29 20,g #200880 <br /> WORK ACKNOWLEDGEMENT FORM AL" <br /> E-MAINTENANCE TICKET NO: ftVa Llb DATE: <br /> FACILITY NO.&ADDRESS: :tt-�A%rj kV ok- <br /> VENDOR NAME&ADDRESS: Q1� VAC <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 LEGULY 0� ��� N �G � j �1�1 \I"5kq— ViVW1VA%r- T14 0,4 <br /> 4 __ <br /> '- �(Y1 <br /> �S 6 'Ssa <br /> cM�S: SS <br /> FEB 12 2016 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑ N LINA ❑ Y ❑N [DNA U ❑ N L1 NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? ❑ Y J N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑N LINA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME : DEPARTURE TIMEm <br /> TOTAL HOURS (MINUS MEALS) •� <br /> TECHNICIAN PRINT ME NA OF DEAVM AGER <br /> TECHNICIA GNA RE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />