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• RETROFIT OR REPAIR • <br />1. Site map enclosed Yes ❑ No ■ <br />2. Spec sheets attached for equipment to be installed Yes ❑ No ■ <br />3. Description of work to be completed: <br />Furnish necessary material & labor to repair / replace #400988932 FE Petro check valve <br />and/or #848480-001 Veeder-Root Pressure Line Leak Detector (PLLD) on (91)Chevron <br />Premium <br />4. Description of equipment to be used: <br />#400988932 FE Petro check valve <br />#848480-001 Veeder-Root Pressure Line Leak Detector (PLLD) <br />S. All equipment is State certified or approved. Yes ■ No ❑ <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? Yes ❑ No ❑ n/a <br />b. Identify contractor performing decontamination: <br />Name: Phone () <br />Address: City: Zip: <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name: Phone: ( <br />Hauler Registration # <br />Address: City: <br />Permitted Disposal Site: <br />EH 23 046 (revised 1/24/02) <br />erspeVp/repss3-623046wpd Page I Wo#126686 <br />Zip: <br />