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by #204087 <br /> � AL <br /> to <br /> � 1c6�'-o,►k5`� WORK ACKNOWLEDGEMENT FORM J,�nf 9✓ �19 : " <br /> E-MAINTENANCE TICKET NO: V—✓15j VJ1-\ DATE: <br /> FACILITY NO.&ADDRESS: <br /> VENDOR NAME&ADDRESS: � - — ��ls.tr 6805 ,Sierra <br /> L <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❑� tY_ ❑N <br /> PLEASE PRINT LEGIBLY `"'� O �L p `L v �S v D�� S �- 1 10 <br /> -1E" (S LkLk. - S .D L t r v rR-eS t - i -P 3 <br /> L i +e s•s t�i �v �-�1G L 112►�-'� �aL�rt',�..� <br /> R <br /> FEB 12 2018 <br /> Are all sensor(s) located at the lowest point? Chain attactied to shear valve? Debris removed from UDC? <br /> Y ❑ N LJ NA ❑ Y J A JY ❑ ❑ NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipme\r.4 repairs <br /> secured and sealed? -�A.Y ❑ N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. JY ❑ ❑ NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME �- ?� DEPARTURE TIME <br /> \ TOTAL HOURS (MINUS MEALS) <br /> { ` <br /> Ck <br /> TECHNICIAN PRINT NAME NA E OF DEALER/ NA <br /> TEC ICIAN AT SIGNATURE OF DEALE50AKGER <br /> DISTRIBUTION: WHITE- Invoice copy / CANARY- Site copy/ PINK-Vendor copy <br />