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+N- • Re0 a <br /> g/xter® ZIPSET® <br /> 3801. 05 <br /> by <br /> VA-00P <br /> WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAME: .�J/�L _ DATE: G•- 3 -z%T- <br /> ADDRESS:74) -S' AUTHORIZATION#: _ <br /> CITY,STATE: S.rz. a _ * FACILITY#AND LOCATION: Ga -eD <br /> SERVICE REQUESTED: <br /> 7'ANK/LINE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST' ❑ ENVIRONMENTAL REPAIRS ( <br /> OTHER ❑ <br /> SERVICES PERFORMED: Y-S 3�2r-0 / .; •�-c 9 � �r.� lf� � <br /> This portion must be completed 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 /> (USE ADDnIONAL FORMS AS NECESSARYI <br /> LIQ D SENSOR CONDITION UPON ARRIVAL <br /> Location ID: 7- (Disc). ,rank ID} Location (Disc) ank ID► <br /> Location: Sum rt>kar� Location. S, U Dom/,,. TDDC ral&r' <br /> Sensor Type: Mechanica / Elec is NA Sensor Type: MecharnZa4 is rA <br /> Located within 1'of I Po Y N / NA located within 1'of I t Pt <br /> N / NA <br /> Is liquid present Y�antity: Is liquid present Y N .duantity: <br /> Is chain attached to shear valve Y / N N� Is chain attached to shear valve Y / N NAS/ <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser pa el Has sump lid or dispens panel <br /> been secured and seal N/NA been secured and sed Y-L�/NA <br /> NUMBER OF PERSONNEL_^ f ARRIVAL TIME '?'' 3 _DEPARTURE TIME Z r✓� <br /> T'OT'AL HOUS INUS S) <br /> PRINT NAME NAME 0-DEA R/MAN ER <br /> t <br /> J f <br /> SIGNATURE S1GN URE' DE R/MANAGER` t�h ,w� <br />