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Work Order: 2272721 <br /> BNH BUSINESS FORMS(714)970.9025 9_52371 <br /> by # 76480 <br /> WORK ACKNOWLEDGEMENT FORM 'AL <br /> lor <br /> E-MAINTENANCE TICKET NO: DATE: Ca' j" <br /> S-13-10 <br /> FACILITY NO.&ADDRESS:" �dnj I� rJ. �(" �� �' +^►Q�} <br /> VENDOR NAME&ADDRESS: n�w�IBgrA <br /> SERVICE REQUESTED: <br /> UTANKAJNETIGHTNESS TEST ACILITYINSPECTION D ENVIRONMENTAL REPAIRS <br /> U VAPOR RECOVERY TEST U SECONDARY CONTAINMENT TESTING D OTHER <br /> D ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARMUMP NO. D UDC/DISPENSER NO. U ANNULAR TANK N0. <br /> ALL ALARMS CLEARED Y U N <br /> . . - <br /> PLEASE PRINT LEGIBLY' S I <br /> Are all sensors)I ated at the lowest point? Chain attacheQ to shear valve? Debris rem oved�fro UDC? <br /> LAY UN JY JNA DY 7N SVA <br /> Have all sum lids anq dispe er panels been ❑ECS N tifled of liquid found in Vapor f <br /> q por equipment repairs <br /> secured and seated? LIN ,D NA containment sumps documented in epa Log? <br /> A only d no sumps or d nsers were opened. ]Y D N U <br /> NUMBER OF PERSONNEL ARRIVAL TIME___ LJ} �Q <br /> DEPARTURE TIME tv� <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT NAME NAME OF DEALERIMANA ER / <br /> Tanknology Inc. 11000 N. MoPac Fxpresm\ay.Suite 500,Austin.Texas 78759 <br />