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B <br />bR V <br />1* WORK ACKNOWLEDGEMENT FORM <br />VENDOR NAME.. �r`T ; -- DATE: <br />ADDRESSA?Wn 0--,Af- AUTHORIZATION #: <br />CITY, STATE: FACILITY # AND LOCATION: ? <br />SERVICE REQUESTED: <br />TANKJLINE TIGHTNESS TEST 0 F ^,CILiTY INSPECTION <br />VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br />OTHER 4 �r- = 7, <br />SERVICES PERFORMED: ^ C.e cs ,lt <br />-71 7Z,4 <br />Tnis portion must be completed by the field technician each time any work is conducted wetnin a dispenser or tan< sum.o, <br />even if that work only consists of a visuai. inspection. Fully executed copies should be distributed as designated on the oottom of each Corm. <br />(USE ADDITIONAL FORMS AS NECESSARY) <br />,.� LIQUID SR CONDITION UPON ARRIYAL <br />Location ID _jr �j.--_ (Disp. #, &n i,'r Location ID _t5�3� Tank ID) <br />Location: <!52V UDC rXnn Location: SumpjBL� Annular <br />Sensor Type: Mechanical / (�c / NA Sensor Type. Mechanical /tom; NA <br />Located within V of lowest Point (�b/ N / NA Located within 1' of lowest Point 4,1�7 N / NA <br />Is liquid present Y / Inuantity• Is liquid present Q N Quantity: �c /An s <br />Is chain attached to shear valve Y / N 1 Is chain attached to shear valve Y ' N /� <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />Has sump iid or dispenser panel <br />been secured and sealed 4(/ N / NA <br />Has sump id or dispenser panel <br />been sec :red and sealed�n / NA <br />NUMBER. OF PERSONNEL --C>l _ ARRIVAL TIME ' l: DEPARTURE TIME <br />TOTAL HOURS (MINUS MEALS) <br />-NAME <br />KU <br />R, <br />PRI T N F DEALER/MANAGER <br />S G;�N�:WWE <br />SIG TU E OF DEALER/MANAGER <br />DIST RI - Attach to Invoice CANARY - Leave at she PINK - Vendor wPY <br />VVCP-3316 (074)21 <br />