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1. <br />2. <br />3. <br />4. <br />is10 <br />RETROFITOR REPAIR <br />Site map enclosed YES NO <br />ptK <br />Spec sheets attached for equipment to be installed YE <br />Description of work to be completed: <br />/�e <br />Description of equipment to be used: <br />0 <br />NO [] <br />�, 0-0 M� A WA WA V Q E M <br />P"rAI&MV041"AMMEN <br />5. All equipment is State certified or approved. Y 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 />2 <br />