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by #200881 <br /> ��,z000i{s4 , � 11119 /\ <br /> io WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: _1��S�%(.� DATE: �.1`QtICIQ_.� <br /> FACI LITY NO.&ADDRESS: AV�D0t)0 'bS C(�.LOV���Q, Wk• t . <br /> GeTTler-Hyart Inc. <br /> VENDOR NAME&ADDRESS: QL\\Aq •6805 Si <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❑YY �❑vN `` <br /> PLEASE P INT LEGIBL • `�/�./4' V- <br /> �.. N <br /> M\v'�'• s 3 <br /> Q��i\icn <br /> FEB 12 2018 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> U ❑ N LJ NA ❑ Y ❑ N DNA ❑ Y J ❑ 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 C-J N ❑ NA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIMETA1rj DEPARTURE TIME �(Yl <br /> CC HH TOTAL HOURS (MINUS MEALS) I-•5 <br /> TECHNICIAN PRINT ME 44ME OF DEALER/MANAGER <br /> TECHNICI IGNATURE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBU N.WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />