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Up <br />0 WORK ACKNOWLEDGEMENT FORM <br />VENDOR NAME-:. DATE: �2 At <br />ADDRESS: Z• _re _ AUTHORIZATION <br />CITY, STATE: FACILITY # AND !LOCATION: _ <br />130 <br />SERVICE REQUESTED: <br />TANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION r-9— <br />V4POR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS Ci <br />OTHER <br />SERVICES PERFCRMED: <br />_ -- A— -:r4- At- ;a f 0.257 <br />This portion must be completes' by the field technician each time any work is conducted within a dispenser or tank sump, <br />even it that work only consists of a visual inspection. Fully executed copies should be distributed as designated on the bottom of each form <br />(USE ADDITIONAL FORMS AS NECESSARY) <br />LIQUID SENSOR CONDITION UPON ARRIVAL <br />Location ID: lD i sp. #, enk.I Location ID: l isp. Tank iDi <br />Location /��r,�r7 DC / nnu Location. Sump / Ann <br />Sensor Type' lvlechanical ronic NA <br />Sensor Type: Mechanical/ Itrom NA <br />Located within V of lowest Poir� N / NA Located within 1' of lowest Poin N / NA <br />Is liquid present Y / 1 7huentity: Is liquid present Y /dvbuantity: <br />Is chain attached to shear valve Y / N / is chain attached to shear valve Y / N /QD <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />Has sump lid or dispenser pa I Hos sump lid or dispenser panel <br />been secured and seale/NA been secured and sealeleD N / NA <br />17 <br />NUMBER OF PERSONNEL ARRIVAL TiME� �_ DEPARTURE TIME ! <br />WCP-33W 107-021 <br />TOTAL [HOURS (MINUS MEALS) / <br />PINK - Vendor copy <br />NAME OF DEALER/MANAGER <br />GNATURE OF DEALER/MANAGER <br />