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RETROFITOR REPAIR <br />1. Site map enclosed YES [] NO [] <br />2. Spec sheets attached for equipment to be installed YES [ ] NO [I <br />3. Description of work to be completed: <br />4. Description of ens sinment to he used: <br />3 <br />of) <br />5. All equipment is State certified or approved_ YES [ ] NO[] <br />g. Decontamination Procedures: <br />a. Will piping be decontaminated prior to removal? YES [I 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 />