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reG ei UO iu; -t (A Iril I LAv 2 a'nmCt_1La1 b'ygCem Ltylbl UOU—lull <br /> 8045801 <br /> by <br /> WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAME: ICYer1V• DATE: <br /> ADDRESS:3-*-3 � rs,�- Q-- AUTHORIZATION#: <br /> CITY, STATE: FACILITY#AND LOCATION: 659 T- <br /> 6100 �U�9-9 <br /> SERVICE REQUESTED: <br /> TA.NKiLINE TIGHTNESS TEST f'e FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ <br /> OTHER 7 <br /> SERVICES PERFORMED: "5s-f <br /> This portion must be cemp(eted by the field technicien each time any work is oonducted withir a dispenser or tank surnc, <br /> even it that work only Co'lsist3 of a visual inspection. Fully exaoutec ropier snould be d atrlouted as desigrated on the bottom of escm form. <br /> (US6 A00I7T0iNAL FORMS AS NECESSARY) <br /> LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location ID; (D'+sp.#,Tank ID) Location ID: !(Disp.#,Tank ID <br /> _ocation. Sump / JDC i Annular Location: Sump / UDC / Annuar <br /> Sensor Type; Mechanical / Electronic i NA Sensor Tyne: Mechanical / Electronic / NA <br /> Located within 1"of lowest Point Y ! N ! NA Located within 1"of iowest Point Y / N / NA <br /> :s liquid prasent Y / N Quantity; Is liquid present Y / N Cuar0y: <br /> Is chain attached to shear valve Y ,` N / NA Is chain attached to shear valve Y / N / NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has stamp lic or dispenser panel Has sump lid or dispenser panel <br /> been-acured arc sealed Y 114 1 NA been secured and sealed Y/N!NA <br /> NUMBER OF PERSONNEL_rAIR RI AI-TIME 7.'(!XO DEPARTURE TIME ID 2 30 <br /> / r _ TOTAL FLOURS(MI MEALS) <br /> PRINT E NANt OF DEALER/MANAGE? <br /> SIGNATURE SIGKATURE OF DEALER/MANAGER <br /> OISIRIBUMN: WHrrE"Attach to Involce CANARY•Leave at site BLUE•BPWCP CompNeaoe copy PINK-Vendor copy <br /> tNCF3315(^7-0Z <br />