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b a 11163 <br /> AL1�U V 22W WORK ACKNOWLEDGEMENT FORM <br /> E-MAI DATE: 4t.14-02 <br /> FACILITY NO.&ADDRESS: <br /> VENDOR NAME&ADDRESS: (�,J' 1-1-3 r ���rv>' �l�ti:� { c q. 9k-LI,04 <br /> SERVICE REQUESTED: <br /> CITANK/LINETIGHTNESS TEST U FACILITY INSPECTION U ENVIRONMENTAL REPAIRS <br /> ❑VAPOR RECOVERYTEST ❑SECONDARY CONTAINMENT TESTING m OTHER /o rml< Awl <br /> U ALARM TYPE AS LISTED ON VEEDER-ROOT PANEL <br /> LOCATION OF ALARM• U SUMP NO. Cl UDC/DISPENSER NO. L]ANNULAR TANK NO. <br /> ALL ALARMS CLEARED U Y U N <br /> PLEASE PRINT LEGIBLY <br /> p.J n ,e fo .fj,fe. ,. S,p !1 �iakt /{� ,r1 ff7 c-11 �vyN• vl.ratf so C�sG. <br /> A AS 1/h, 03ty l,�a allo arm 7:T a <br /> r <br /> Are all sensor(s)located at the lowest point? Chain attached to shear valve? Debris removed from UDC? <br /> L11 UN SNA U ON IRNA U UN,14aNA <br /> Have all sump lids and dispenser panels been 0 ECS Notified of liquid found in Vapor equipment repairs <br /> secured and sealed? ❑Y ❑N LrNA containment sumps documented in Repair Log? <br /> A only if no sumps or dispensers were opened. ❑Y ❑ N U NA <br /> NUMBER OF PERSONNEL 2 ARRIVAL TIME 2'00 DEPARTURE TIME �f:*0 <br /> TOTAL HOURS ( �f- <br /> MINUS MEALS) <br /> ^ <br /> l�'@''C e,vii•ey <br /> TECHNICIAN PRINT NAME 'N E OF DEALER/MANAGER <br /> 1,, <br /> TECHNICIAN SIGNATI.AkE SIGNATURE OFDEALER/MANAGER"" <br /> DISTRIBUTION:WHITE-Invoice copy / CANARY-Site copy/ PINK-Vendor copy <br />