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LIST SYSTEM RETROFIT OR REPAIR <br />1. Site map enclosed YES [ ] NO [] <br />2. Manufacturers spec sheets attached for all equipment to be installed YES I I NO [ ] <br />mimgmiir;xo& <br />a <br />5. AD equipment is State certified or approved. YES [] NO [] <br />.7 = <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 />769 t 70rs174 =4 , <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phone( Hauler Reg#_ <br />Address City Zip <br />Permitted Disposal Site <br />7. a. Describe the method that will be utilized to purge andlor inert the piping: <br />b. Piping Hauler. <br />Name Phone <br />Address City zip <br />Hiude'r, Registration # (if hauled as hazardous) <br />c. Piping Disposal Site: <br />Name Phone <br />Address City. zip <br />EPA 113# (if transported to a permitted TSD facility)_ <br />9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br />10- Handling of excavated so1 (Contaminated Soil Hazardous Waste Hauler): <br />Narne Hauler R"Istra&w # Phone <br />Address —city_ zip_ <br />1-ITM,lnri• .'- <br />