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ap #200921 <br /> 44-11�0— <br /> WORK ACKNOWLEDGEMENT FORM ®� <br /> E-MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS: 2,"_. <br /> .,Mer nr <br /> -nydn Inc. <br /> VENDOR NAME&ADDRESS: 0-305Sierra <br /> SERVICE REQUESTED: -uJlir., Iv,� 94563 <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING ❑ 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 /> PLEASE PRINT LEGIBLY: C l7�-6 <br /> 6�C — <br /> , <br /> - ------— ------- --- <br /> Are all sensor(s)located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> 4Y U IJ NA L11 ❑ N ANA ❑ Y ❑ N A'NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? AY ❑N ❑NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑N 4 NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME 0g10 DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> 7 fS <br /> TECHNICIAN PRINT NAME NA D ERIMAN <br /> TECHNICIAN SIGNATURE SIGNA URE O DEA troiA1Q ER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />