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by <br /> 0 WORK ACKNOWLEDGEMENT FORM <br /> VENDOR I'AIt_IV" Contraictors) InCDATE: <br /> 2535 VIgwam r. _ .... . . <br /> ADDRESS:SWCTIT,CA-9� —AUTyOR17AT1DN <br /> CITY, STATE: __ FACILITY##AND LOCATION'__1 7 <br /> SERVICE REQUESTED: <br /> i <br /> TANK/LINE TIGHTNESS TEST 0 FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST p ENVIRONMENTAL REPAI 3S p <br /> OTHER ,V e. !' 01c <br /> i <br /> I <br /> SERVICES PERFORMiED:FQVW7pG� iJl ��/ .l G„r�J ' 7 I� (�, `T , •1{„ <br /> yNTrC3l�Jt};'.. ecf. t.1N.e-/V­," • �JC( C 7 v�'_ tjtr PU11_ <br /> U Vv i,.-)It Yt'<' I �- i'r f( 1`g° r t` ,) C. <br /> 7C) LfC `���, �r. G�'✓�'�l 1 �..f /.,fE(.. ',.G) fin./ 'tc0 F,J t'A!C_ L h / l�. <br /> I <br /> 1 „L <br /> This portion must be completes by the field technician each time any work is conducted within a dispen ier or tank sump, <br /> even if that work only consists-.fa visual inspection. Fully executed copies should be distributed as designated on the bottom of each form <br /> (USE ADDITIONAL FORMS AS NECESSARY) <br /> K "� LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location ID: f ! (Disp.#,Tank ID) Location ID: <br /> (Disp.#,Tank IDI <br /> Location: toWgr/ UDC f Annular Location: Sump / UDC / Annular <br /> Sensor Type: Mechanical ' Eimvb?i / NA Sensor Type: Mect anical / Electronic / NA <br /> Located within t"of lowest Point �f" N / NA Located within V of lowest Point Y / N / NA <br /> Is liquid preser)t--</ N Quantity:_,�G� f-LCJf�` Is liquid present Y I N Quantity: <br /> Is chain attached to shear vvive- %�N / NA is chain attached to Shear valve Y / N /`NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser p inel Has sump lid or disp anser panel <br /> been secured and seated --fI 717— been secured and sealed Y/N/NA <br /> / , ­ <br /> / <br /> - <br /> NUMBER OF PERSONNEL. '~f --ARRIVAL TIME I�_DEPARTURE TINIE .3 <br /> TOTAL HOURS(MINUS MEALS) <br /> uPRll� NAME OF DEALER/MANAGER <br /> kIGNATURE SIGNATURE OF DEALER <br /> DISTRIBUTION: WMITE-Attach to voice CANARY-Leave at site PINK-vendoroopy <br /> WCP-3316(07-02) <br />