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# '17979 <br /> brp A L <br /> 14100#0091.- WORK ACKNOWLEDGEMENT FOR <br /> 110F, M <br /> S" SZO <br /> E-MAINTENANCE TICKET NO: DATE: Y 7 .5 <br /> FACILITY NO.&ADDRESS: 20-/10 /6/ <br /> VENDOR NAME&ADDRESS: S TA <br /> SERVICE REQUESTED: <br /> ❑TANK/LINE TIGHTNESS TEST U FACILITY INSPECTION U ENVIRONMENTAL REPAIRS <br /> U VAPOR RECOVERY TEST J SECONDARY CONTAINMENT TESTING ;4OTHER 2_z:j) <br /> U ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM LJ SUMP NO. U UDC/DISPENSER NO. U ANNULAR TANK NO. <br /> ALL ALARMS CLEARED Ll Y U N <br /> PLEASE PRINT LEGIBLY: � 5/Zc- 0"'i J C�' <br /> 71 r, "C'C'u t i <br /> Al % z 5 7-*Jl <br /> z 24- <br /> 7 <br /> SX5 717Lzz.- <br /> 3,C, Tpave, <br /> All <br /> Mila- <br /> 0A <br /> =4Z- <br /> Are all sensor(s) looted at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> L-1 Y UN NA U Y LIN Qlq_A� Ll Y U N urkA <br /> Have all sump lids and dispenser panels been Q ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? IJ Y U N a-N--A containment sumps documented in RepairLog? <br /> ,VA only if no sumps or dispensers were opened. LJ Y LJ N 4ff <br /> J <br /> NUMBER OF PERSONNEL ARRIVAL TIME J0 :al-l-, DEPARTURE TIME <br /> _7 <br /> 7- /yA0 TOTAL HOURS (MINUS MEALS) T <br /> xy <br /> Te <br /> TE <br /> TEOHNICIAN PRINT NAME NAME OF DEALER/MANAGER <br /> 6&bMa UNAL il-__ <br /> TECHNICIAN SIGNATURE SIGNATURE IEALER/MAGER <br /> DISTRIBUTION:WHITE-Invoice copy f CANARY-Site copy/ PINK-Vendor copy <br />