Laserfiche WebLink
BNH BUSINESS FORMS(714)970-9025 <br /> bp # 216115 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: I Q 2Q) Qq-1�A DATE: 1 ` V <br /> FACILITY NO.&ADDRESS: nk O t>o <br /> VENDOR NAME&ADDRESS: <br /> SERVICE REQUESTED: <br /> U TANK/UNE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING KOTHER <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 LEGIBLY oti c ✓r _ <br /> cL r 3 t. r� <br /> t ^ 5R IY u d o - c� <br /> o'h 06 v �►..,c�C�S �. 1_ <br /> u <br /> Wdl <br /> ` <br /> Z ac r f c,(^� f t // C <br /> c c w^v 2 aT 1 a �� kJ G ch) /-b 2,)e, �f <br /> C <br /> wo.14�f . 1 vu o <br /> 1 1p s � <br /> V��,,� r•o ���ocrr �,(rCr — w2 w;l ac�dvest u s n.s (` v c�Il rn dam < a(vc- <br /> L.i �c✓�, <br /> �� s�nn.ps wl�+cl, is � s�1.-�` �•� w�.wh-r •Ca u.�( 20@ S¢,�-svJ ��{'.o a�ar�-. <br /> Are 11 sensor(s)located at the lowest point? Chain attached toshear valve? Debris removed from UDC? <br /> JQY ❑ N LINA ❑Y D JNA U ❑ N_.L:1I�A <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in <br /> q Vapor equipment repairs <br /> secured and sealed? FeK ❑N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑N TVA <br /> NUMBER OF PERSONNEL !i ARRIVAL TIME DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> avl 3�00MOS <br /> TECHNICIAN PRINT NAME NAME OF DEALER/MANAGER <br /> TECHNICIAN SIGNATURE SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />