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RETROFIT OR REPAIR <br /> 1. Site map enclosed YES [] NO TA <br /> 2. Spec sheets attached for equipment to be installed YES [A NO [ ] <br /> 3. Description of work to be completed: <br /> T-a.LL EA> X SW V V.A-P o rL Ce-5 S -20010 G E AtL E-T(s,vr m rL— <br /> 9 ►� 9' I S `�'P "'b 0 2/'-C r. 4 Af qya-c. !/lit 0 At GTr0 aA -L r, <br /> CGRT �Fc �' DiTroxQ • <br /> 4. Description of equipment to be used: <br /> UA-Po2 LEss 2000 <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 /> 2 <br />