Laserfiche WebLink
nab iu Uf UL:d5p Carrie Brown (209) 4a1-6342 p.6 <br />B ?23116 <br />byAft- <br />r <br />WORK ACKNOWLEDGEMENT FORM <br />I; <br />VENDOR NAWO IV COMIUA4IQ . ImTE: L <br />2535 Wlgwalm �Dr. <br />kDDRESS: _ AUTHQR!ZATICN #: <br />C171 Y, STATE' {{ FAC.L TY # AND LOCATII)N: j 7 <br />�1 <br />SERVICE REOUESTED: <br />'ANK/LINE TIGHTNESS TEST ❑ FACILITY INSPEC-ION ❑ <br />VAPOR RECOVERY TEST ❑ ENVIRONMENT REPkRS O <br />OTHER 17 L �yi.1- <br />SERVICES PERFORMED: C 1 l.`C3 V\, SG � <br />L ` <br />'ns oor:ion must be cemal9:ec by 711 f*-cl TsCrijcian each time an• vrork is coreiaaa within a 1 spenser ei tank sump, . <br />e:+en if :hat vjo,k ,r,? co"is.0 of a AYual ins-ett,on. FUMY exa9Ut6o copies shQula ae d,strlbuted as des'.gnated on tme noncm of .Nacn form. <br />IUSE ADWIONAL H)RMSAS NECASSARyI <br />j LIQUID SENSOR CONDITION UPON ARRIVAL <br />Location IC: �_ l (Disp. M, T k i�� Looetior ID Nisp M Tank ILS) <br />Lcoation: um ULnC 1 Annular Location: Sump ; UDC / Annular <br />Sonsar Type: Iv;echan;cai I PIA Sensor Type: Mechanica i Electronic / %A <br />Located w to r 1' of lowest R, mZ5 N / NA Located w&!n 1' of lowest Point Y I N / NA <br />Is liquid :resent Y /6usntity: ls;;quid Gresent Y / N 1048111 TV: <br />Is :neu, attached tc smear valve Y / N / lA Is train attachee to slietar valve Y / N ; NA <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />Hsi sump lip a ciscenser panel Has sump lid or asponsor parer <br />been securec and aeeledcj N / NA been securad and sealed v! \ / NA <br />n,;MSER OF PEPSONNEL ARRIVAL TIME Ly-) DEPARTURE TME r� — r 1 �x' <br />�.•'- V <br />TOTAL HOU (MINUS MEALS) <br />PRINT NAME: NAME OF DEA R/MANAGER ► <br />'46�� - AN qj k G III r cl��A <br />SIGNA7 E SIGNAT _ OFD R/ AGER <br />NMI UT N: WHILE • Attach to lmolaa CANARY • Leava mills PUNK • Vandmeo0v <br />