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Signature �� 4 <br />EH230038 <br />(revised 1/31/02) <br />RETROFIT OR REPAIR <br />1. Site map enclosed YES [7f NO [ ] <br />2. Spec sheets attached for equipment to be installed YES Pq NO[] <br />3. Description of work to be completed: <br />_Addition on existinn _canopy 26' x 24' and fueling island_ addition to increase <br />fueling dispensers by one, 2 fueling points <br />4. Description of equipment to be used: <br />1 Wayne V590- 3 Product, 2 Hose Dispenser <br />1____ Environ 2816-2 Dispenser Pan -with Safety Valve,_ Stainless Flex Connector <br />1--_— VeederRoot 794380-208 Liquid Sensor <br />'__ Environ GeoFlex_Double Wall Product Piping and Geo Dust and Fittings <br />5. All equipment is State certified or approved. YES P9 NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [ ] N04 ] <br />b. Identify contractor performing decontamination: (No Piping Will Be Removed) <br />Name Phone( ) <br />Address City Zip <br />I% <br />