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by # 159736 <br /> 0 Q WORK ACKNOWLEDGEMENT FORM <br /> ORM <br /> E-MAINTENANCETI KETNO. ( IOmo DATE: <br /> RECEMED <br /> FACILITY NO.&ADDRESS: :02_1Y& 32-/2 /4• Cc�ij%rj; s G � ��1,;; U 3 2014 <br /> ue e an-MC. <br /> VENDOR NAME&ADDRESS: 6805 Sierra Court, Suite G ENVIRONMENTAL.. <br /> SERVICE REQUESTED: Dublin, CA 94568 _;1#P 1 - - <br /> ❑TANK/LINE TIGHTNESS TEST *ACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> Lk VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TEST]NG ❑ OTHER <br /> ❑ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM ❑SUMP NO. ❑UDC/DISPENSER NO. ❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED❑Y ❑N <br /> �jL_EASE PRINT LEGIBLY•1 <br /> Lt." t <br /> l 2 s yn <br /> VED- <br /> T r-%ar an <br /> Zk_1 Travel <br /> Uv" - <br /> ppQtS— Vol w, �c�.L Ino <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ N ❑NA J ❑ N ANA ❑ Y J XNA <br /> Have all sump lids and dispenser panels been ❑ECS Noted of liquid found in Vapor equipment repairs <br /> secured and sealed? )'Y ❑N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened- ❑ Y ❑ N )4IA <br /> NUMBER OF PERSONNEL Z ARRIVAL TIME DEPARTURE TIME <br /> F,lod s. <br /> V)WS r� TOTAL HOURS (MINUSM LS) <br /> TECHNIIAN P T NAME NAME OF DEALER/ GER <br /> Yl— <br /> TECHNI AN SIGNATU E S U�FLEFA/WNAGE�.. <br /> DISTRIBUTION: WHITE- Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />