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by Ay # 159490 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> 0 <br /> !� <br /> E-MAINTENANCE TICKET NO:�Q'[ i �L�� DATE: ��� <br /> FACILITY NO.&ADDRESS: z' Q } <br /> ettTerRyan-- nuc. <br /> VENDOR NAME&ADDRESS: <br /> SERVICE REQUESTED: Dublin, CA 94568 <br /> J TANK/LINE TIGHTNESS TEST J FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> J � <br /> VAPOR RECOVERY TEST 0 SECONDARY CONTAINMENTTESTING ,OTHER <br /> J ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM J SUMP NO. 0 UDC/DISPENSER NO. J ANNULAR TANK NO. <br /> ALL ALARMS CLEARED 0 Y J N <br /> PLEASE PRINT LEGIBLY• <br /> tmf <br /> fig g As <br /> ,L <br /> G S, <br /> `Y <br /> I 'ales: <br /> Are all sensor(s) located at the lowest point? Chain attached to shear vaI e? Debris removed from UDC? <br /> JN JNA JY JN 4NA ❑Y JN .WNA <br /> Have all sump lids anddis enser panels been J ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. 0 Y 0 N QtCNA <br /> NUMBER OF PERSONNEL / ARRIVAL TIME DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> ����, <br /> H IAN PRIN AME NAME OF DEALER/MAN _ <br /> TECH IAN SIGN RE .,-SIGNATURE /MANAGER <br /> DISTRIBUTION:WH I E-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />