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1�1y;10N� 14: 24 4640:38 ENVIRONMENTAL HEALTH PAGE 02 <br /> RETROFIT.OR REPAIR 1.01 <br /> 1. Site map enclosed YES NO [J <br /> 2. Spec sheets attached for equipment to be installed YES' NO [J <br /> 3. Description of work to be completed: <br /> 4. Description of equipment to be used: <br /> 5. All equipment is State certified or approved. YES J, <br /> NO [) <br /> 6. Decontamination Procedures: fvj/ - <br /> 1 YES [] NO [ ) <br /> a. Will piping be decontaminated prior to removal? <br /> b_ Identify contractor performing decontamination: <br /> Name Phone`_.___) <br /> Address City —Zip <br /> C. <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 /> Phone( ) <br /> Hauler Name <br /> 2 <br />