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Signature,_ <br />Keith A. Tallia, President <br />EH230038 <br />(revised 1/31/02) <br />RETROFIT OR REPAIR <br />1. Site map enclosed YES [ ] NO [A <br />2. Spec sheets attached for equipment to be installed YES [ ] NO <br />3. Description of work to be completed: <br />ReplaQe Line Leak Detector on Regillar Tank Tjirbjj3P Plimpi <br />4. <br />Description of equipment to be used: <br />Red Jacket 116-0056-5 <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 />2 <br />