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# 1 8 5 14 <br /> bp AL <br /> xt�141,C®6,1101, WORK ACKNOWLEDGEMENT FORM <br /> 241- ISO. <br /> EC E IVEff"" <br /> E-MAINTENANCE TICKET NO: DATE: <br /> FACILITY NO.&ADDRESS: --YAS ZtLl <br /> VENDOR NAME&ADDRESS: i,j F <br /> r <br /> SERVICE REQUESTED: <br /> U TANK/LINE TIGHTNESS TEST Uki-4CILITY INSPECTION IJ ENVIRONMENTAL REPAIRS <br /> U VAPOR RECOVERY TEST 0 SECONDARY CONTAINMENT TESTING C3 OTHER <br /> U ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM SUMP N0. 1:3 UDC/DISPENSER NO. J ANNULAR TANK NO. <br /> ALL ALARMS CLEARED Q Y Q N <br /> PLEASE PRINT LEGIBI-Y- <br /> N <br /> Are all sensor(s) located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> �—Y 13N 0 NA FJ Y Q N NA U Y UN KNA <br /> Have all sump lids and dispenser panels been L-3 ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? V 13 N Q NA containment sumps documented in Repair Log? <br /> �A only if no sumps or dispensers were opened. LAY U N CNA <br /> Cr() <br /> NUMBER OF PERSONNEL ARRIVAL TIME DEPARTURE TIME <br /> TOTAL HOURS (MINUS MEALS)_ <br /> uA'AL <br /> TECHNICIAN PRINT NAME NAM OF DEALERWNAGER <br /> A <br /> TECKNICIAN S SIGq4UAE OF DEALER/MAN N <br /> DISTRIBUTION:��fflnvoicecopy CANARY-Site copy/ PINK <br />