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by U # 158728 <br /> io � - <br /> WORK ACKNOWLEDGEMENT FORM " <br /> E-MAINTENANCE TICKET NO: G DATE: —� 7 <br /> FACILITY NO.&ADDRESS: Z RW <br /> VENDOR NAME&ADDRES 11MR-C iNc <br /> SERVICE REQUESTED: DUBLIrT CAI.IF01M 9456F <br /> ❑TANK/LINE TIGHTNESS TEST a FACILITY INSPECTION a ENVIRONMENTAL REPAIRS" <br /> ❑VAPOR RECOVERY TEST O SECONDARY CONTAINMENT TESTING OTHER 11 � c <br /> 0 ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM ❑SUMP NO. L)UDC/DISPENSER NO. d ANNULAR TANK NO. <br /> ALL ALARMS CLEARED 0 Y ❑N <br /> PLEASE PRINT LEGIBLY <br /> C <br /> J rl1 <br /> t <br /> to 4&r <br /> Travel <br /> U E 1 <br /> M MAR 12014 <br /> NNles: <br /> Are all sensors) located at the lowest point? Chain attached to shear valve? / Debtis removed from UDC? <br /> J L) NA ❑ Y ON aY LJNAdNA <br /> Have all sump lids and dispenser panels been ❑ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? di0*—LIN LJ NA containment sumps documented in Repair Log? <br /> �A only if no sumps or dispensers were opened. _ ❑Y ❑ N Z NA <br /> NUMBER OF PERSONNEL it ARRIVAL TIME :U DEPARTURE TIME3., <br /> ' A-1— TOTAL HOURS (MINUS S) <br /> 1A) -rk ��h In ate' <br /> CH RINT N pe NAME OFD AGEER� <br /> A, <br /> " <br /> TECH ICIA AT E S NATURE OF L R/MANAGER <br /> DISTRIBUTIO 'WHITE- Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />