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bp 1-7 ZG 1 -501k. # 180474 <br /> WORK ACKNOWLEDGEMENT FORM <br /> E-MAINTENANCE TICKET NO: F,o 'o- 7q 6 S— DATE: 02 <br /> &C'V J UTL--� LSF--tom ,m i i <br /> FACILITY NO.&ADDRESS: 185- a LOy 1 S f-r AVE Lf►T4#2oP CP� MAR 6 9Hr— <br /> Gettler-lRyan Inc. <br /> VENDOR NAME&ADDRESS: <br /> SERVICE REQUESTED: Dublin, CR 94568 E V'V1^0NVi'77NTAL t-;rALT <br /> ❑TANK/LINE TIGHTNESS TEST ❑FACILITY INSPECTION WNVIRONm&: rAL REPAIi�b T <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:_ SET IJ7_ ►._���—AfPEP_3P� _ <br /> _'__ 1 N.�Pe'c�t� ��+t'�l� v,�✓es o^1—��sP_--- �/z� ��� L�atS --N�- -- <br /> -GGjp CS FoJN D <br /> -- <br /> e�i.�lEr -LLi4L t/rS_ 7D -t 0 Ss1 C C_r''� _�e-ac-- <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> J ❑ N QNA ❑ Y ❑ N SPNA U J NbNA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? �PY ❑ N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ N .d NA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME/SG CG DEPARTURE TIME <br /> /7 TOTAL HOURS (MINUS MEALS) <br /> --72 <br /> TECHNICIAN PRINT N / N ME OF DEALER/MANAGER <br /> TE . ',N AN SIGN TURE SIGNATURE OF DE ER <br /> DISTRIBUTION: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />