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BNH BUSINESS FORMS(714)970-9025 <br /> by # 216115 <br /> •s= _w WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: _w ZO DATE: 1 ` ZA ` I�l <br /> IFACILITY NO.&ADDRESS: <br /> VENDOR NAME&ADDRESS: <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESS TEST IJ 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 I❑SUMP NO. ❑ UDC/DISPENSER NO. ❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED❑Y ❑N I <br /> PLEASE PRINT LEGIBLY' <br /> 1 ' <br /> C,L" Iva V CC 5 vp..e 1 5R I,,S 6 y is 't�,O c --f ue rP 1 "f i C�1T <br /> of h 01 VN J00WL-,Xf <br /> � �1 <br /> Z Jr. ,.� Gii l 1 C ✓ <br /> t0 c, a %VNrL% <br /> ` c., c1,2 , . <br /> 14,1- <br /> SLA Ion CLV—,�7 - f ;-�,�r�< i f 1u( <br /> �"r-rc wot rntc.va <br /> tVo'y*� 0VVJ ' r-yk( GV2 O �v Y�V J S 1r.c 1 t-LX tt� ✓Pa Cul /�vL i ►/c✓/. <br /> - 1 L-, <br /> G} S�nn.ns whc� 4S Yom Soh.11 0 cw.w r V, 20,, c,I Vv ys-, <br /> 7II sensor(s) located at the lowest point? Chain attached�tosh�shear valve? Debris removed from UDC? <br /> ❑ N ❑NA ❑ Y ❑ N SNA J ❑ N_L�k-ISA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in <br /> J� ❑ N ❑ NA q Vapor equipment repairs <br /> secured and sealed? containment sumps p documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y J N—a-19A <br /> NUMBER OF PERSONNEL 2— ARRIVAL TIME DEPARTURE TIME <br /> ( TOTAL HOURS (MINUS MEALS) <br /> cvl �c MA w �1I <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 />