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mad le 04 CI:2ap Carrie Brown (209) 461-6342 <br />p.4 <br />B15G82-'- <br />by <br />Aolbt <br />WORK ACKNOWLEDGEMENT FORM <br />VENDOR"Ilflw —DATE: aZ-ps ._ 1 <br />^DDRES .535 IIiIC��CBttI� fy AUTHORIZATION #: �2 <br />c�anl CA �� t 1 <br />C TY, STATE: _ 205 FACT LIT' # ANC LOCATION <br />SEPV CE REQUESTED: <br />TANK/ fNE TIGHTNESS TEST ❑ FACIL7Y'NSPECT!ON <br />VAPOR RECOVERY 7EST ❑ aNVIRONMENTAL REPAIRS 7 <br />07H ER 11 9 1 d D W �'% <br />SE;V CES PERFORMED: <br />16 <br />q <br />l t Imo. <br />r�v\v� ar <br />Tl,,in parlcr -..�.yt be comoIVed by the field tocFnlcian Dacn tir-a any work s cora xted wtmir E espenserer tank sums.. <br />ever ;f that wark only COnairs of o visaal inspati�n. FU Iv exea'Jted cc*-ag snDUIC be jistr,b�,tad as dss'gnetec onthe of eac:i firm <br />IVBB ADOITrONAI FORMS As r4JOWARY) <br />n LIQUID SEEISOR CONDITION UPON ARRIVAL <br />_ooaticn D: �1 ;Disc. t+, n''k l Location ID {Disc. 0, Tenn ID) <br />_oca; on: Sl.vip I UCC / nru Lcoetiom Sump / JDC / A.nno:w <br />.ersor Type; Mechanical / 45527-7 71 NA SenserType: Mechanical 1 Electronic I NA <br />_ocsted within t' of loweet Fein? / N / NA "coated wth,n 1" of lower. Point Y ! N 1 NA <br />Is liqulc p'esent Y p(DQuvntity: Is liquid present, Y / N Quantity: <br />'s ,;nein attached to shear valve Y / "J "I7- Is chain attached to s-,�d3' va ve Y ; N ! NA <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />was surrp id or dlscensa• panel Hes sump lid or dispenser pare <br />caen securec and sealed•16 N I NA beer secured and sealed Y / N 1 NA (� <br />^ WASER OF PERSONNEL _ aRRIVAL'IME S DEPARTURE TIME <br />TOTAL HOURS (MINUS MEALS) '�C ' �'� �� `✓ <br />Lk <br />PRINT NAM7-NAME OF DEALER/MANAGER <br />!GN USE SIGNATURE OF DEALER/MANAGER <br />DISTIVISLMON: WHInt • Attach to Invoice CANARN • Dave it slim PINK • Marder aooy <br />-t 3r 0 !07-C2- <br />