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carr: a srown ( 209) 461-6342 P. 3 <br />Elite IV Contractors. Inc. 8159695 <br />by 2533 Wigwam Dr. <br />Stockton, CA 95206 t 47- <br />41 ' <br />,Z WORK ACKNOWLEDGEMENT FORM <br />VENDOR NAME: DATE:_ <br />ADDRESS_�i c sZSM AUTHORIZATION #: o <br />CITY. STATS:UC, 'C FACILITY # AND LOCATION: <br />;' `v 5.Z3 <br />SERVICE RECLIESTED: <br />T NiVL NE TIGHTNESS TEST C FHCIJTY INSPECTION <br />VAPOR RECOVERY TESTll Q C <br />ENViRNMENTAL REPAIRS <br />. <br />OTHER J � l C-1. Okd—: V\, <br />SERVICES PER;:CRMED: <br />rte. i4- `? (c- UI )� (Q ;S•- <br />7ni; porticn nest _e composted by Ts t eld technician each erre ary work Is conyucted wthln a dispenser or terk sum.. <br />s.o- if 1n3' wort >n'-, -orsisiz cf a visial lrspopuon. N ly axawted copies shc,rid be diStrikutad as eesignatec -,n ti,e cotton^ o' each Urm <br />(USEADDRWNAL FCAMS AS 14ECESSARY1 <br />/ LIQUID SENSOR CONDITION UPON ARRIVAL <br />_c.ativn i^. _-_ -( - iDisp. #. Tank Di Location ID: (D:sp, M, -ark !D <br />:oca'.icn Sump !UCCArnui Location: Sump ! UDS ;Annular <br />Sar -Type: ecnaricel Eiectrcric NA SersorType: tvecharical / Elecl-onic ! NA <br />Lcoatea with M ' " of awest oc Mt N / NA Located wits:r t o' 'owest Point Y / N / NA <br />is liquid weger'. .v ; c1ua^tity: is liquid present Y ; N Quantity <br />fs cha,r attacrrod t: shear valve Y 1 N /( vA~ Is ens r attached to rhea, v�, ve Y / N / NA <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />Has sumc' a OF cispalser el I -es sump iia or dispenser )anal <br />been secu'ed ar.d sealed ON / NA beer securec and seaie,, Y/ N / NA <br />PIIJhJ:3"eR O= PERSONNEL � APR IVAL '71 NA I _5-_L—PARTUR2 TfNiE —%—L <br />15 <br />TOTAL HOURS (MINUS MEALS) <br />PR„!NT NAME NAME OF DEAjEMANA _R <br />.� 2.R/ <br />SIGNAT qE TONATURE OF DEAL R/N'ANAGER <br />DISTRt6UTI N. 'NNT6 - Attach to Involee CANARY • Lave atslte PINk - Vondoa dopy <br />�11C? 223'8 <br />