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by �(jL�� �"� # 150377 <br /> WORK ACKNOWLEDGEMENT FORM " <br /> _ I �r <br /> E-MAINTENANCE TICKET NO: DATE: -0 / /� <br /> FACIUTYNO.&ADDRESS: <br /> VENDOR NAME&ADDRESS: 6747 SIERRA COURT,STE.J <br /> SERVICE REQUESTED: f� 94568�— <br /> ❑TANK/LINE TIGHTNESS TEST dFACILITYINSPECTION QENVIRONMENTAL REPAIRS <br /> 0 VAPOR RECOVERY TEST 0 SECONDARY CONTAINMENTTESTING 0 OTHER <br /> 0 ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL _ <br /> LOCATION OF ALARM 0 SUMP NO. 0 UDC/DISPENSER NO. 0 ANNULAR TANK NO. <br /> ALL ALARMS CLEARED 0 Y 0 N <br /> PLEASE PRr LEGI YJ <br /> t� <br /> tY <br /> Are all sensor(s)located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> 0Y DN DNA 0Y U ONA DY UN ONA <br /> Have all sump lids and dispenser panels been O ECS Notified of liquid found in Vapor equipment re <br /> secured and sealed? 0Y 0 N 0 NA containment sum Pyre <br /> Ps documented in Repair Log? <br /> VA only if no sumps or dispensers were opened. 0 Y D N 0 NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME /2 DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> TECHNICIAN PRINT N E OF DEALER/ 'IAG'�E�R� <br /> U / r <br /> TECHNICIAN SIGNATURE GNATURE OF R/MANAGER <br /> DISTRIBUTION:wHfTE-Involce copy I CANARY-Site copy I PINK-Vendor copy <br />