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Elite IV Contractors, Inc. B 1,� 9 6 0 8 #, <br /> 10 2 Wlgwam Dr. <br /> 535 , <br /> , � <br /> by Stockton, &A 95245 <br /> Ak WORK ACKNOWLEDGEMENT FORM <br /> VENDOR NAME: DATE: <br /> ADDRESS: AUTHORTLON #: <br /> r <br /> CITY, STATE; <br /> FACILITY ITY# LOCATION:-WZ;� <br /> SERVICE REQUESTED: <br /> TANK/UNE TIGHTNESS TEST ❑ FACILITY INSPECTION ❑ <br /> VAPOR RECOVERY TEST ❑ ENVIRONMENTAL REPAIRS ❑ /t <br /> OTHER 2"1*- �� �►� � L-C���.�- 7 J,����y�..�..J`�ti�i <br /> q / <br /> SERVICES PERFORMED: --- 7 <br /> <t 7,-,' <br /> U n <br /> rex SU e_ 725G /i�Lov -rte <br /> to <br /> + e_ `. lv � r�t�Jr ftp! , !re- j' / <br /> S <br /> 'J <br /> This portion must be completed by the field technician each time any work is conducted within a dispenser or tank sump, <br /> even it that work only consists of a visual inspection. Fully executed copies should be distributed as designated on the bottom of each form. <br /> (USE ADDITIONAL FORMS AS NECESSARY) <br /> LIQUID SENSOR CONDITION UPON ARRIVAL <br /> Location iD: (Disp.#,Tank ID) Location ID: r G' {Disp.#,Tank ID) <br /> Location: Slimp-i U,QL„�-A,nnular Location: Swaap.iil-,UDC 1 Annular <br /> Sensor type: Mechanical /-EWcz"o4o -NA Sensor Type: Mechanical 1 Fi,=wci(- i NA <br /> Located within 1"of lowest Point-411-iff-/ NA Located within 1"of lowest Point?-T-N / NA <br /> Is liquid present Y /entity: Is liquid present Y /,W -Quantity: <br /> Is chain attached to shear valve Y / N / NA Is chain attached to shear valva •Y / N ! jJe,•._..—.._._. <br /> LIQUID SENSOR CONDITION UPON DEPARTURE <br /> Has sump lid or dispenser panel Has sump lid or dispenser panel <br /> been secured and sealed been secured and sealed Y/N/NA <br /> NUMBER OF PERSONNEL ARRIVAL TIME1�4 [ DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS) <br /> PRINt N NAME OF DEALER/MANAGER <br /> \", , I i6t,� <br /> S NAT ATURE EALER/MANAGER <br /> DISTRIBUTION: WHITE-Attach to invoice CANARY-Leave at site PINK-Vendor ao <br /> VVCP-3316107.02! <br />