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0 RETROFIT OR REPAIR 0 <br /> 1. Site map enclosed YES [ ] NO X Y,`evi Ntjy Sabm+ffed <br /> 2. Spec sheets attached for equipment to be installed YESNO [ ] <br /> 3. Description of work to be comleted: <br /> I cv <br /> -fir bA 4f 4,11 acid 4'e Pnalu4 -,o;11 bxkd-odl 1;Y121e%e C-VK eer���d <br /> r o'n value, -Ql ad4d)yr, and egmI&L oaa. Per&rnihs�rlla�rbn ����,;-�� 0-5 Ke :-e- <br /> Jou Ex(ndimiQrder V 4o- )-e :5pJllh Pf k lis, cvd a ilk" in Hca �' <br /> as re4&,v�pd [�; SiT Gam. Inv hazardxrs lWel w apae.'al.� c�,J%/� �'�s.�as 1" � <br /> �.LIIJL'S IE'Gtdio�Ft:�� Ha4Ardet y �,xasl e.�►cry <br /> 4. Description of equipment to be used: D V15wn. <br /> b P 1 'a 'e t-e s re ;U l e r <br /> IEx au �i✓-e Ord-er V tZ -lo.? -LE. : See a 1Lched aa'45 Cask -a llw <br /> epee S)'7'e-et5 . <br /> 5. All equipment is State certified or approved. YES , NO [ ] <br /> 6. Decontamination Procedures: <br /> a. Will piping'tdecontaminated prior to removal? YES [ ] NO [ ] <br /> b. Identify contract erforming decontamination" <br /> Name Phone(_) <br /> Address city Zip <br /> C. Describe method to be used r d ontamination: <br /> d. Describe how rinsa material will be stored - site prior to manifesting offsite: <br /> e. Rinsate uler and permitted Treatment, Storage & Dispo I Facility: <br /> Hauler Name PhoneL_) <br /> 2 <br />