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by UADL�7 � # 1162959 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> &MAINTENANCE TICKET NO: ZZ 13 DATE: Z,5- /t. IFF <br /> FACILITY NO.&ADDRESS- <br /> VENDOR NAME&ADDRESS: <br /> SERVICE REQUESTED: 6805 Sierra Court, Suite G <br /> ❑TANK/LINE TIGHTNESS TEST Dublin,Gt%C8 SPECTION QENVIRONMENTAL REPAIRS <br /> Q VAPOR RECOVERY TEST QSECONDARY CONTAINMENT TESTING MOTHER <br /> Q ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM 0 SUMP NO._ a UDC/DISPENSER NO. ❑ANNULAR TANK NO, <br /> ALL ALARMS CLEARED Q Y ❑N <br /> PLEASE PRINT LEGIBLY: <br /> MAR 02 2616 <br /> 6 <br /> �1h_�1r,c <br /> Af <br /> Are all sensor(s)located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> SLY Q L)NA QY U SIA QY LIN ;kNA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in <br /> q Vapor equipment repairs <br /> secured and sealed? I(Y Q N Q NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. <br /> OY LIN $NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME DEPARTURE TIME <br /> TO*UR S M LS)__ 7 <br /> TECHNICIAN P NAME R/MANA ER <br /> NICIAN SIGNATURE F DEALER/MANAGER <br /> DISTRIBUTION:WHITE-Invoice copy ! CANARY-Site copy/ PINK-Vendor <br />