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by # 204780 <br /> fo ��'1� WORK ACKNOWLEDGEMENT FORM " <br /> flc --�� <br /> r �1/ <br /> E MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESSA� gj�, , 31. <br /> VENDOR NAME&ADDRESS: 2 ttler-RYan Inc. <br /> :s <br /> SERVICE REQUESTED: <br /> Dublin, CA 94r7,68 <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. \�^ M� - <br /> t/•'J C,, t'j I sa, <br /> RECD JAN 0 3 2018 <br /> Are all sensor(s) located t the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> Y ❑ N ❑ NA ❑ Y ❑ N A L11 ❑ N NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liqui ound in Vapor equipment re airs <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 qNA <br /> NUMBER OF PERSONNEL ARRIVAL TIME '�� DEPARTURE TIME t — � - <br /> TOTAL HOURS (MINUS MEALS) <br /> Z�— " c4cz."I,,G' <br /> TECHNIC PRINT NAME NAME E OFD LER/M GER <br /> TECFqCIAN SPKATIJRE SIGN RE OF DEALER/MANAGER <br /> DISTRIB :WHITE-Invoice co / CANARY-Site copy/ PINK-Vendor copy <br />