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by # 194674 <br /> *VA -WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: �'�'� L+-%0 to DATE: I' ��_ —1 <br /> %o�. ett er- yanInc �s <br /> FACILITY NO.&ADDRESS 6805 Sl rra Gnj irt, A utP r <br /> VENDOR NAME&ADDRESS: DUblin. CA 94568 <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESS TEST LJ FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> Ll VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING LlOTHER <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 <br /> R <br /> n CPAlgT ZE NT <br /> b• �,,�•1-t- ��.ri r� S Gtr S� <br /> IF-D MAR Os '{J1 <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑ N`-I�ill,NA J U 3-QA U ❑ N —ONq <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? 'taZ ❑ N ❑NA containment sumps documente Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y LI NN ❑ A <br /> NUMBER OF PERSONNEL ARRIVAL TIME 1-�''— DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT NAME M OF ER/MANAGER <br /> TECHNICIA SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION: WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />