Laserfiche WebLink
Feb 20 07 07:44p <br />Pauli .,rarner <br />17076931 p..6 <br />B 455191 <br />2u- f2 y <br />WORK ACKNOWLEDGEMENT FORM <br />VENDOR NAME: _ DAZE:_— <br />GE iTLER RYAI+T INC AUTHORIZATION #: <br />CITY. STATE! ti FACILITY # AND LOCATION: _ <br />--- <br />SERVICE REQUESTED: <br />TANK/LINE TIGHTNESS TEST El FACILITY INSPECTION D <br />VAPOR RECOVERY TEST D ENVIRONMENTAL- REPAIRS D <br />OTHER - �_ C <br />SERVICES PERFORRME'D/j_r/��/,{„� <br />✓`�"'�_...L��-'�.__-QL'IL_.'S ��. y�� /,✓T /-s � r�fK.sT r,.��s-_. <br />C V1 <br />�. -fit <br />This portion must be completed by the field technician each time any work is conducted within a dispenser or tank sump <br />even if that work only conaisis of a visual inspection Fully ozewtad copies should be distributed as desigreted on the bottom of each form. <br />IUSE ADOrr1ONAL FORMS A6 N=ESSAAYl <br />LIQUID SENSOR CONDMON UPON ARRIVAL <br />Location ID: (Disp a Tank ID) L.ocation ID: . (Disp C Tank ID) <br />Location: S m J UDC / Annular location: Sump / UDC / Arrnulal <br />Sensor Type: echanical J Electronic 1 NA Sensor Type: Mechanical / Electonle / NA <br />Located whhin I' of lowest Point Y / N J NA Located within 1' of fewest Point Y / N / NA <br />s liquid present Y / N Quantity:.•_- Is liquid present Y 1 N Ouantity: <br />Is chain attached to shear valve Y J N / NA Is chain attached to shear valve Y / N J NA <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />Has sump fid or dispenser panel Has sump fid or dispenser panel <br />been secured and sealed Y / N / NA ' c been secured and sealed Y l N J NA <br />NUMBER OF PERSONNEL _ ARRIVAL TIME / / JCC DEPARTURE rIME <br />TOTAL HOURS (MINUS MEALS) '+G" <br />_j <br />PRINT N;WE r NAME OF DEALER/MANAGER T <br />SIGNATURE SIGN, 11RE OF DCAO.RNANAGER <br />D1SMSUrIM YME -Atter to irnwioa CAti W Lamm Kfkf PM • Vander copy <br />WCR3316107-02) <br />Tralrel <br />Vk: _ <br />