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by # <br /> q WORK ACKNOWLEDGEMENT FORM ©© <br /> © 7 <br /> E-MAINTENANCE TICKET NO: DATE: 1 <br /> FACILITY NO.&ADDRESS -L� <br /> VENDOR NAME&ADDRESS: � ttleM r-Ryan Inc. <br /> ;x <br /> SERVICE REQUESTED: Dublin, GA 94568 <br /> ❑TANK/UNE TIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENTTESTING ❑ 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 ,\-9 Mf '7a S-r CAW"'� T ST r! <br /> l/ 'J C./ 1j so. <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 LIN ❑NA ❑ Y ❑N A ❑ Y ❑ N NA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liqui ound in Vapor equipment repairs <br /> secured and sealed Y ❑N ❑NA 1;1 containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑N q NA <br /> NUMBER OF PERSONNEL L ARRIVAL TIME '�� DEPARTURE TIMEA� <br /> TOTAL HOUR (MINUS MEALS) <br /> TECHNIC PRINT NAME NAME OF DFALER/M GER <br /> TECF4CIAN SJQKATLIRESIGN RE OF DEALER/MANAGER <br /> DISTRIB :WHITE-Invoice 4// CANARY-Site copy/ PINK-Vendor copy <br />