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RETROFIT OR REPAIR I* <br />1. Site map enclosed YES tf NO[] <br />2. Spec sheets attached for equipment to be installed YES,& NO [ ] <br />3. Description of work to be completed- Yin 5 �'a` t �j P L:) 1E k e -c -t Y'i C2- <br />V\ <br />2v\ r' h s a <br />12 <br />i S�P,tiS21r'' ���2yy"e� Fax <br />- <br />4. Description of equipment to be used: <br />LhJi,rov, -l" ��(2 iov► �P_�3�C® <br />5. All equipment is State certified or approved. YES (L NO [ ] <br />6. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? N / A YES[] NO[] <br />b. Identify contractor performing decontamination: /t/1A <br />Name Phone(,_) <br />Address I City Zip <br />C. Describe method to be used for decontamination: AJ/A <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />LLA <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />N/ <br />Hauler Name 1A Phone(�.�) <br />2 <br />