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Signatu <br />EH230038 <br />(revised 1/31/02) <br />M <br />RETROFIT OR REPAIR <br />1. Site map enclosed YES [ ] NO W See Tank Monitoring Program submitted 8/13/03 <br />2. Spec sheets attached for equipment to be installed YES NO[] <br />3. Description of work to be completed: <br />Replace red jacket mechanical leak detector <br />4. Description of equipment to be used: <br />V"orless brand model 99LD 2000 mechanical line leak detector <br />-64 03111'4Z32 -- <br />5. <br />1/4Z32 <br />5. All equipment is State certified or approved. YES] NO [ ] <br />6. Decontamination Procedures: N/A <br />a. Will piping be decontaminated prior to removal? N/A YES [ ] NO [ ] <br />b. Identify contractor performing decontamination: N/A <br />Name N/a Phone(_) Nva <br />Address N/A city Zip <br />Oa <br />