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• OR REPAIR <br />1. Site map enclosed YES [ ] NOV <br />2. Spec sheets attached for equipment to be installed YES NO <br />3. Description of work to be completed: <br />MM MINE 11 <br />I i &A , 3 (A T -e- s <br />4. Description of equipment to be used: <br />I o -W M ez, <br />5. All equipment is State certified or approved. YES NO <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES[] NO[] <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 />Fd <br />