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' #200921 <br /> WORK ACKNOWLEDGEMENT FORM AALIF <br /> E-MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS: ' zlxff . z7-12 1I- � tt J-OPN t k <br /> �eer- yan Inc. <br /> VENDOR NAME&ADDRESS: 0305 <br /> SERVICE REQUESTED: Olublin, CA 945(,-31 <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:( /_.- �l�£� s x _. <br /> L��SP�Yrtf1__ ,ca,� 6 ,t4pL/� d� u�Eb�i j - c ra/ oe <br /> HALO-AZ Al-l ©,k _— <br /> c3U 10 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> AY ❑ N ❑ NA ❑ Y ❑ N ANA ❑ Y i❑ N WNA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? A Y ❑ N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y JN J1 NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME 09—;C5 DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) - <br /> TECHNICIAN PRINT NAME NA D ER/MAN <br /> TECHNICIAN SIGNATURE SIGNATURE O DEA f41MNA ER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY- Site copy/ PINK-Vendor copy <br />