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Signature <br /> EH230038 <br /> (revised 1/31/02) <br /> RETROFIT OR REPAIR <br /> 1. Site map enclosed YESfj NO [] <br /> 2. Spec sheets attached for equipment to be installed YES kj NO[] <br /> 3. Description of work to be completed: <br /> * Installation of Blueline Technologies UL listed piping penetration and conduit <br /> penetration split repair boots on existing UST sump penetration points, and <br /> subsequent SB-989 testing. <br /> 4. Description of equipment to be used: <br /> Blueline Technologies UL listed SB and SR series repair boots and repair <br /> reducers. (See attached Product and UL information) <br /> 5. All equipment is State certified or approved. YES NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? N/A (x) YES [] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name NLA _ Phone(_) N/A <br /> Address N/A City n/A Zip n/A <br /> 2 <br />