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` B 363322 <br /> i <br /> i <br /> by I <br /> ''x'1019"• WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAME: e_09yi6i � �> DATE: h-ZZV10 <br /> ADDRESS: 2e2 i/r'::-, dzIL AUTHORIZATION#: 9-2e_-- <br /> CITY, STATE: �� T, FACILITY#AND LOCATION: (6�a Le Oyu <br /> Gct _J/_1 31.0 der 3'�) <br /> SERVICE REQUESTED: <br /> TANK/LINE"LIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST O ENVIRONMENTAL REPAIRS ❑ <br /> OTHER <br /> SERVICES PERFORMED: f 5 Sw <br /> I <br /> i <br /> This portion must be�compieted by the field technician each time any work is conducted within a dispenser or tank sump, <br /> even if that work only consists of a visual inspection. Fully executed copies should be distributed as designated on the bottom of each form. <br /> (USEADDITIONAL FORMS AS NECESSARY) <br /> LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location ID: (Disp.#,Tank ID) Location ID: (Disp.#,Tank ID) <br /> --s <br /> Location: Sump � Annular Location: Sump / UDC / Annular I <br /> Sensor Type: Mecham I / ectronl / NA Sensor Type: Mechanical/ Electronic / NA <br /> Located within 1°of lowest Poin / N / NA Located within 1"of lowest Point Y / N / NA <br /> Is liquid present Y / uantity: Is liquid present Y / N Quantity: <br /> Is chain attached to sear valve Y / N / `A� Is chain attached to shear valve Y / N / NA <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser panel Has sump lid or dispenser panel <br /> been secured and sealed(ON/NA been secured and sealed Y/N/NA 7 <br /> NUMBER OF PERSONNEL ' ARRIVAL TIME 0 3 c DEPARTURE TIME <br /> TOTAL. HOURS (MINUS MEALS) <br /> PRINT.NAME <br /> AWE OF 4DEAMEIMA AGER <br /> SIGNATURE' SIGNATURE OF DEALER/MANAGER <br /> DISTRIBUTION:WHITE-Attach to invoice CANARY•Leave at site PINK-Vendor copy <br /> WCP-3316(07-02) <br />