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31s1 O't C)4 <br />bP <br />0 WORK ACKNOWLEDGEMENT FORM <br />t'r IV CCRItrectiors, InDATE. 0!01009 <br />vENDOR <br />AUTHORIZATION #: <br />ADDRESS.-SFACILUIIVN*ANDLOCATI <br />CITY, STATE'... <br />SERVICIE REQUESTED' <br />TANKILINE TIGHTNESS TEST <br />VAPOR RECOVERY <br />-OTHER <br />SERVI <br />FACILITY 114SPECTION <br />ENVIRONMENTAL REPAIRS <br />:r <br />c <br />Or Wk sumP, <br />his Pzjcn Inust '>e 00npiqlad i;y she field technician conductactwithin a dispemef <br />m. <br />even that work ontr consists of a visual jnspqotion. Fully executed COP168 Should be zlisttibLted as designOted On the 00tt"n Of each 10 <br />JUSE ADDMNAIL WNS AS NECOWY) <br />LfQUID SENSOR CONDIITION UPON AR71VAL <br />(Dj3p. 0, Tank 0 <br />(Disp, 0, Tank IDI Location !D: <br />Location: L MP IJDC I Annular Locatior: Sump / UDC Annular(f> sctr ' NA Sensor Type: Mecnaniva: Electronic NA <br />Sensor Type �Aechauical --15 <br />Pant N / NA Locatad Wthn 1' of llp est Point V i N j t1A <br />�Cetl- V ni�t <br />Located withir V of I 0 -OW POi It <br />is i0quid zrasew Y I(S�)Quwtiiw: Is liq--id present <br />> <br />IS chain attached to rhea' varve Y I N i(*NA Is chain attached to shear valve Y/NG <br />LIQUID SENSOR CONDITION UPON DEPARTURE <br />H&S Sump lid oi dispenser panel Has sump lid or dispenser al <br />I A a 7" <br />sealed N 1 NA been secured ail sealed 9; N / NA <br />veen. <br />ARRIVAL DEPARTURE wmSER OF PERSONNEL_ RETIME <br />TOTAL HOURS fMINUS5 MEALS) <br />*e C-11 <br />ev / <br />&Z--� <br />PRINT NAME NAME OF DEALER/MANA ER <br />5 17G INA lot'. N UR OF DEALS NAGER <br />as -MB sob, 1111-1kc CANMY • LOWO *111"* PINK <br />0. 87 V.MUTRF • AIV1.0 <br />.S [ON: 1Y <br />wCF-3315107-m <br />