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by # 156255 <br /> #YJ WORK ACKNOWLEDGEMENT FORM 'AL <br /> 40-y- <br /> E MAINTENANCE TICKE / VO//-3d DATE: _ �//q AZ <br /> FACILITY NO.&ADDRESS: G,� S r <br /> VENDOR NAME&ADDRESS: 6747 SIERRA COURT, STE.7 <br /> SERVICE REQUESTED: tN,0% Or N <br /> ❑TANK/UNETIGHTNESS TEST ❑FACILITY INSPECTION ❑ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERY TEST ❑SECONDARY CONTAINMENT TESTING ❑ OTHER <br /> ❑ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL q1 F/16 4-66,0"— <br /> LOCATION OF ALARM ❑SUMP NO. ❑UDC/DISPENSER NO. _❑ANNULAR TANK NO. <br /> ALL ALARMS CLEARED❑Y ❑N <br /> PLEASE PRINT LEGIBLY: S�%� u n S Cko.�✓— <br /> &V Y 001,0 S oPISSI141,/-' 12602 6V-k- I.e Vii, >YG,S-.- Z4 .te--yz <br /> —,LCL <br /> T174 12,Gr�iy�2t /Y � .d <br /> i� <br /> ray <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> ❑ Y ❑N L11 NA ❑ Y ❑N ❑ NA ❑ Y ❑ N LINA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in "Vapor equipment repairs <br /> secured and sealed? ❑Y ❑N ❑ NA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑ Y ❑ N ❑ NA <br /> NUMBER OF PERSONNEL_ ARRIVAL TIME 9,,C2y 4,4 DEPARTURE TIME Z;uy <br /> TOTAL HOURS (MINUS MEALS) - S, o <br /> TECHNICIAN F�iINiR <br /> -- - NAME OF 6ALER MANA — <br /> / GER <br /> TECHNICIAN SIG - S NAT LERlMANAGER <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />