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B ;'zz ( i If <br /> by <br /> WORK ACKNOWLEDGEMENT FORM <br /> VENDOR N/ifite IV Contractors, Inf;ATE: 67 <br /> ADDRESS: 2535 Wigwam Dr. AUTHORIZATION#, <br /> CITY, STATE: ____ FACILITY#AND LOCATI DN: "1 <br /> t�. t ` <br /> SERVICE REQUESTED: <br /> TANKILINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPA RS ❑ <br /> OTHER 9 I._.s!�b dL A P. -. nr DTA <br /> SERVICES PERFORMED: va� <br /> If <br /> This portion must be complet(d by the field technician each time any work is conducted within a dispe iser or tank sump, <br /> even if that work only consists of a visual inspection. Fully executed copies should be distributed es dr signated on the bottom of each form. <br /> (USE ADDITIONAL FORMS AS NECESSARY) <br /> LIQUID SENSOR CONDITION UPON ARR11AL <br /> 7 - 1 <br /> Location ID: �`�^r ( _(Disp.#,Tank ID) Location ID: (Disp.#,Tank ID) <br /> Location: -Stvnpl/ UDC / Annular Location: Sump / UDC / Annular <br /> Sensor Type: MatV6 cal% Electronic / NA Sensor Type: Mel:hanical / Electronic / NA <br /> Located within 1"of loaves,Point,�"/ N / NA Located within 1"cf lowest Point Y / N / NA <br /> Is liquid present Y / N Quantity: Is liquid present Y / N Quantity:_­ <br /> Is chain attached to shear falve Y / N /,RA Is chain attached to shear valve Y / N / NA <br /> 1 <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser panel Has sump lid or dispenser panel <br /> been secured and sealed `'i i14;NA been secured and:;ealed Y/N/NA <br /> NUMBER OF PERSONNEL. ARRIVAL TIMEf�Tl DEPARTURE T ME <br /> TOTAL HOURS(MINUS IAEALS) <br /> o.I)PRINT NAME ', NAME OF DEALER AQ�EIR <br /> SIGNATURE SIGN, URs OF DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Attach t4Involee CAIIMMY•Leew 811:4140 POW-Vendor copy <br /> WCP.3316(07-02) <br />